HX00011606 


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^y  J.  i..con4rd  Corning,   M.A., 


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A  TREATISE  ON 

HYSTERIA  AND  EPILEPSY, 

WITH 

SOME  CONCLUDING  OBSERVATIONS  ON 
EPILEPTIC  INSOMNIA, 


J.  LEONARD  CORNING,  M.  A.,  M.  D., 

ConsuHant  in  Nervous  Diseases  to  St.  Francis  Hospital ;    formerly  one 
of  the  Resident  Physicians  to  the  Hudson  River  State  Hospital  for 
the  Insane  ;    Fellow  of  the  New  York  Academy  of  Medicine  : 
Member  of  the  New  York  Neurological  Society,  of  the  Amer- 
ican Neurological  Association,  of  the  Medical  Society  of 
the  County  of  New  York  of  the  Physicians''  Mutiial 
Aid  Association,  of  the  Medical  Society  of 
the  State  of  New  York 
Author  of  "^  Treatise  on  Headache  and  Neuralgia,''   '^  Brain  Rest, 
being  a  DLsquisition  on  the  Curative  Properties  of  Prolonged 
Sleep,"  '  Local  Anaesthesia,"  "'Brain  Exhaustion, 
with  Some  Preliminary  Considerations  on 
Cerebral  Dynamics,"  ''Carotid 
Compression"  etc. 


GEORGE  S.  DAVIS, 

DETKOIT,  UICH. 


Copyrighted  by 

GEORGE    S.   DAVIS. 

i88S. 


TO  THE  MEMORY  OF  MY  MATERNAL  GRANDFATHER, 

FREDERICK  DEMING, 

THESE    PAGES    ARE    INSCRIBED  AS  A  SLIGHT    TOKEN    OF 

AFFECTION    AND    ADMIRATION    FOR    HIS 

NOBLE    QUALITIES    OF    HEART 

AND    MIND. 


NOTE. 

One  year  ago  I  published  a  series  of  papers  on  "  Epi- 
lepsy"  and  "  Hysteria,"  which  articles  appeared  in  the  "New- 
York  Medical  Journal  "  and   "  Gaillard's  Medical  Journal." 

The  present  publication  is  an  amplification  of  those  studies, 
which,  as  they  now  appear,  possess,  to  all  intents  and  pur- 
poses, the  qualities  of  a  systematic  treatise. 

26  West  47th  Street,         ) 
New  York,  July  30th,  1888.  )" 


TABLE  OF  CONTENTS. 


PART 


HYSTERIA. 
CHAPTER.  PAGE. 

I.  Introductory  Note — Definition i 

II.  Symptomatology — Psychical  Manifestations 4 

III.  Sensory  Disorders — Hyperaesthesia 25 

IV.  Sensory  Disorders  Continued — Anaesthesia 37 

V.  Motor  Disorders — Spasms — Paralysis 41 

VI.  Vaso  motor  Disorders — The  Hysterical  Cough. ...  49 

VII.     The  Hysterical  Paroxysm 57 

VIII.     Hysteria  in  Children — Hysteria  in  Men 62 

IX.     Causation — Pathology — Diagnosis 68 

X.     Prognosis — Treatment 74 

PART  II. 

EPILEPSY. 
CHAPTER.  PAGE. 

I.     Classification — Symptomatology-Symptoms  which 
Immediately  Precede  the  Attack — Aurae  Epi- 

lepticse 83 

II.     The  Manifestations  of  the  Epileptic    Paroxysm — 

Grand  Mai go 

III.  The  Manifestations    of    the    Epileptic   Paroxysm 

Continued — Petit  Mai — Seizurers  Character- 
ized by  Loss  of  Consciousnes  and  Local 
Spasms 05 

IV.  Masked  Epilepsy gg 


VIII. 

PART  II— EPILEPSY— Continued. 

CHAPTER,  Page. 

V.     "Thalamic"    Epilepsy — Jacksonian    Epilepsy — 

Sensory  Epilepsy 103 

^  VI.     Causation 109 

— -VII.     Experimental  Researches 117 

VIII.     Experimental  Researches  Continued 123 

IX.     Patho-anatomical  Findings 139 

X.     The  Mechanism  of  the  Epileptic  Seizure 142 

XI.     Concerning  the  Nature  of  the  Irritation — Theories 

of  Nothnagel,  Todd  and  Hughlings  Jackson.  .  152 

XII.     Prognosis — Treatment 157 

XIII.     Treatment  Concluded — Epileptic  Insomnia 163 

Index , 171 


HYSTERIA. 


CHAPTER  I. 

INTRODUCTORY  NOTE— DEFINITION. 

So  heterogeneous  and  multitudinous  are  the  symp- 
toms of  the  disease  known  as  hysteria  that  an  exact 
description  of  the  affection  is  exceedingly  difficult,  and 
an  adequate  definition  little  short  of  impossible. 

We  can  be  certain,  however,  that  a  large  propor- 
tion of  the  manifestations  of  the  affection  are  directly 
attributable  to  a  functional  derangement  of  the  brain 
and  spinal  cord,  while  not  a  few  of  the  phenomena 
are  probably  traceable  to  a  morbid  condition  of  the 
sympathetic  and  peripheral  nervous  system. 

It  is  impossible,  moreover,  to  regard  hysterical 
phenomena  as  the  result  of  other  than  purely  func- 
tional disturbances  of  the  nervous  system,  since  patho- 
logical anatomy  has  failed  to  afford  other  than  '  nega- 
tive data.  Nor  is  it  probable  that  much  enlighten- 
ment as  to  the  ultimate  morphology  of  the  disease  is 
to  be  anticipated  from  purely  patho-anatomical  sources 
On  the  contrary,  if  we  are  ever  to  be  informed  as  to 
the  nature  of  the  occult  pathology  involved,  it  is  un- 
doubtedly to  a  future  pathological  chemistry  that   we 


are  to  look  for  such  knowledge.  When,  too,  the  pres- 
ent incompleteness  of  physiological  chemistry  is  borne 
in  mind,  there  is  evidently  no  immediate  prospect  of 
enlightenment  from  that  source,  were  our  metaphysi- 
cal endeavors  ever  so  great.  It  cannot,  therefore,  be 
said  that  the  probabilities  of  early  enlightenment  upon 
the  subtle  pathological  changes  which  lie  at  the  root 
of  hysterical  phenomena  are  considerable. 

Whatever  the  ultimate  nature  of  these  changes 
may  be,  we  may  nevertheless,  rest  assured  that  they 
must  be  wide-spread  in  character,  since  only  on  the 
basis  of  such  an  assumption  is  it  possible  to  account 
for  the  heterogeneous  array  of  symptoms. 

For  the  present,  then,  hysteria  may  be  regarded 
as  a  general  neurosis  of  the  nervous  system,  character- 
ized by  psychical,  motor,  sensory,  secretory,  vaso- 
motor and  reflex  derangements.  The  justification  for 
including  symptoms  of  so  heterogeneous  a  nature  un- 
der one  common  designation  has  been  questioned. 
But,  on  the  other  hand,  it  has  been  urged  that  all 
these  symptoms,  though  not  always,  are  frequently 
associated  in  one  and  the  same  individual,  so  that  the 
assumption  that  they  are  all  attributable  to  one  gener- 
al cause  seems  in  a  measure  justifiable. 

Be  the  merits  in  the  case  what  they  may,  we  shall, 
at  all  events,  adhere  to  current  usage,  if  for  no  other 
reason  than  to  avoid  uncertain  and  profitless  dis- 
cussion. 

Dismissing  this  portion  of   the   subject,    we    will 


—  3  — 
content  ourselves  with  but  one  more  observation,  be- 
fore proceeding  to  give  a  comprehensive  description 
of  the  affection.  Owing  to  the  circumstance  that 
hysteria  is  found  to  prevail  to  a  greater  extent  among 
women  than  men,  and  also  to  the  fact  that  changes  in 
the  condition  of  the  female  genital  organs  exert  an 
undoubted  influence  upon  the  development  of  hysteri- 
calphenomena,  it  has  been  assumed  that  hysteria  is  an 
affection  exclusively  confined  to  females.  Moreover, 
the  same  line  of  reasoning  has  led  to  the  assumption 
that  hysteria  is  invariably  the  result  of  a  diseased  con- 
dition of  the  genital  organs. 

The  integrity  of  the  first  portion  of  this  proposi- 
tion simply  depends  upon  the  breadth  of  significance 
which  we  give  to  the  term  hysteria.  Most  certainly  a 
lachrymose  condition,  accompanied  by  laughter  and 
choking,  is  found  in  men,  as  I  have  already  had  oc- 
casion to  show  in  former  communications.*  But 
whether  the  more  serious  manifestations  of  the  affec- 
tion are  found  in  the  male  sex  has  been  questioned. 

On  the  other  hand,  the  second  portion  of  the 
proposition — that  which  assumes  that  hysteria  is  in- 
variably the  result  of  uterine  or  ovarian  disease — may 
be  dismissed  without  further  comment  as  manifestly 
opposed  to  a  vast  sum  of  clinical  evidence. 


*  Brain  Exhaustion.     By   J.    Leonard   Corning,    M.    D., 
New  York,  D.  Appleton  &  Co.,  1884.  p.  116,  et  seq. 


CHAPTER  II. 

SYMPTOMATOLOGY— PSYCHICAL       MANIFESTA- 
TIONS. 

Symptoms. — The  disease  usually  develops  gradu- 
ally, though  in  certain  cases  there  is  apparently  a 
sudden  exacerbation  of  symptoms,  doubtless  attrib- 
utable to  the  fact  that  the  prodromata  had  been 
overlooked.  In  another  category  of  cases,  however, 
the  onset  of  the  disease  is  evidently  sudden,  the  attack 
coming  on  in  the  course  of  a  few  days  in  persons  pre- 
viously healthy.  Thus  it  sometimes  develops  after 
sudden  fright  and  grief,  or  after  acute  diseases  or  se- 
vere hemorrhage.  Cases  of  this  kind  must,  however, 
be  regarded  as  constituting  rather  the  exception  than 
the  rule;  but  they  are  not  the  less  worthy  of  attention, 
since  a  knowledge  of  the  possibility  of  their  occur- 
rence will  serve  to  prevent  many  an  error  in  diagnosis. 
This  form  of  onset  is  frequntly  characterized  by  the 
occurrence  of  one  of  those  paroxysmal  seizures  so 
peculiar  to  hysteria.  We  shall  take  occasion  to  refer 
at  length  to  those  convulsive  phenomena,  in  connec- 
tion with  the  discussion  of  the  motor  manifestations 
of  the  disease.  For  the  present  we  will  content  our- 
selves with  observing  that,  although  we  shall  adhere 
as  much  as  possible  to  a  systematic  discussion  in  the 
following  description,  no  corresponding  chronological 
order  is  really  found  in   the   disease   itself.     Indeed, 


—  5  — 
there  is  no  affection  in  the  whole  range  of  medicine 
the  symptoms  of  which  are  subject  to  greater  varia- 
tions than  those  of  hysteria.  As  a  consequence,  the 
order  of  discussion  adopted  in  any  description  is  pure- 
ly a  matter  of  convenience,  and  is  utterly  devoid  of 
objective  significance,  as  far  as  the  disease  itself  is 
concerned.  Since  mental  disturbances  are  usually 
among  the  earliest  and  most  characteristic  manifesta- 
tions of  the  disease,  it  will  be  well  to  take  up  their 
consideration  first,  though  this  is  not  the  method 
usually  adopted  in  the  books. 

Psychical  manifestations. — A  certain  mental  exalt- 
ation, accompanied  by  extreme  irritability,  is  the  most 
obvious  psychical  symptom.  The  inhibitory  power  of 
the  intellect  over  the  emotions  seems  suppressed;  the 
subject  yields  herself  with  apparent  indifference  to 
sentiments  of  the  most  opposite  character;  joy  suc- 
ceeds sorrow,  as  evinced  by  alternate  attacks  of  laugh- 
ter and  crying;  there  is  an  apparent  complete  paralysis 
of  volition. 

As  a  direct  result  of  these  chaotic  and  ebullient 
emotions,  the  patient  becomes  exhausted  and  peevish. 
She  is  excited  and  moved  to  immoderate  annoyance 
by  the  veriest  trifles;  or  perchance  an  exactly  opposite 
condition  of  things  is  engendered,  and  she  signifies 
approval  in  terms  so  extravagant  as  to  cause  amuse- 
ment and  astonishment  to  those  about  her.  By  de- 
grees, however,  the  susceptibility  to  pleasant  emotions 
diminishes,  as  the  exhaustion  consequent  upon  the  in- 


—  6  — 

ordinate  psychical  output  becomes  greater  and  greater. 
And,  as  a  final  result,  disagreeable  emotions  become 
preponderant.  At  the  same  time  a  chronic  tendency 
to  introspection  becomes  established,  a  condition 
which  culminates  in  one  of  the  most  disagreeable  and 
at  the  same  time  characteristic  manifestations  of  hys- 
teria, a  morbid  craving  for  sympathy.  The  subject  be- 
comes completely  absorbed  in  what  she  considers  her 
deplorable  condition,  and  thinks  and  talks  of  her  ail- 
ments without  ceasing.  As,  by  degrees,  her  friends 
become  accustomed  to  these  lamentations,  and  by  as- 
cribing them  to  imaginary  causes,  fail  to  render  the 
customary  sympathy,  she  becomes  desperate.  Her  in- 
ordinate egotism  is  offended;  to  her  distorted  vision 
there  is  but  one  commanding  personage  in  the  uni- 
verse— herself — in  comparison  with  whom  the  rest  of 
mankind  are  as  nothing.  But,  like  many  a  royal 
egotist,  while  heartily  despising  the  ways  of  the  ple- 
bian  portion  of  humanity,  she  is  eminently  anxious  to 
obtain  its  plaudits  and  servility.  How  to  obtain  an 
endless  sympathy  from  obdurate  mankind,  without 
the  slightest  return,  is  the  great  question  to  the 
hysterical,  the  cord  from  which  all  their  present  and 
future  hopes  hang  suspended.  In  order  to  obtain  the 
coveted  boon,  the  whole  moral  nature  is  trampled 
under  foot;  prevarication,  false  witness,  theft,  and 
even  murders,  are  the  means  to  which  resort  is  had, 
when  the  milder  expedients  of  constant  lamentations 
and    weeping  have  failed  to  keep  the  sympathy   of 


—  7  — 
family  and  friends  up  to  the  desired  standard.  These 
crimes  of  the  hysterical,  committed  apparently,  in 
many  cases,  without  the  slightest  tangible  reason, 
form  one  of  the  most  extraordinary  chapters  in  the 
whole  range  of  criminal  jurisprudence. 

The  following  history,  furnished  by  Cullingworth,* 
is  an  illustration  of  a  case  of  this  kind: 

"  In  December,  1876,  a  girl  of  eighteen  was  found 
one  evening  standing,  with  her  clothing  wet  and 
muddy,  and  in  an  apparently  stupefied  condition,  in 
the  closed  doorway  of  a  restaurant  in  the  centre  of 
Manchester,  a  few  yards  from  where  she  was  lodging. 
She  was  taken  home  and  put  to  bed,  and  a  medical 
man  was  sent  for.  He  found  her  to  all  appearance 
unconscious  of  what  was  going  on  around  her,  and 
uttering  some  disjointed  and  incoherent  complaints  of 
having  been  drugged  and  threatened.  He  thought 
she  was  recovering  from  the  effects  of  some  narcotic, 
and  did  not  at  first  pay  much  attention  to  her  story. 
The  following  day,  however,  she  appeared  worse,  and 
in  the  evening  her  condition  was  considered  so  critical 
that  the  police  were  communicated  with,  with  a  view 
to  her  statement  being  taken  down.  She  was  visited 
by  two  experienced  detectives,  who,  seeing  how  mat- 
ters stood,  and  having  the  doctor's  assurance  that  she 
was  in  a  dying  state,  sent  at  once  for  a  magistrate, 
before  whom  she  made  a  solemn  declaration  to  the 


*  Cited  by  Ross,  op.  cit.,  p.  855. 


following  effect:  she  believed  herself  to  be  dying.  On 
the  previous  evening  a  solicitor,  at  whose  office  she 
had  called  on  business,  told  her  that  she  must  go  into 
a  convent,  and  gave  her  some  sort  of  dark,  sweet 
drink,  which  rendered  her  senseless.  On  going  down 
stairs  from  the  office,  she  met  a  Jesuit  Father,  whom 
she  had  met  once  before.  This  gentleman  pulled  her 
along  the  street  to  a  little  house  in  a  court,  where 
there  was  an  upper  room  with  a  bed  in  it,  and  a  cross 
on  the  wall.  Having  got  her  into  this  room,  he  said 
improper  things  to  her,  and  gave  her  a  little  cake, 
which  affected  her  directly.  The  woman  of  the  house 
came  into  the  room  and  found  her  on  the  floor,  after 
which  she  somehow  got  outside;  the  priest  following 
her,  again  dragging  her  along  in  the  dirt  to  the  street 
corner,  when  he  ran  away." 

"  The  solicitor  and  the  priest,  both  of  them  well 
known  and  highly  respected,  were  thereupon  placed 
under  arrest  in  the  middle  of  the  night,  on  the  charge 
of  having  administered  certain  poisonous  drugs  with 
intent  to  murder.  The  story  was  proved  to  be  purely 
imaginary,  and  the  magistrate  dismissed  the  case." 

Self-mutilation  is  sometimes  practiced  by  hysteri- 
cal patients  in  order  to  obtain  sympathy.  The  follow- 
ing is  a  case  in  point,  which  was  reported  some  years 
since  by  Dr.  Channing:* 

"  Mrs.  Miller  was  first  seen  by  us  in  1875,  a  month 


*  American  Journal  of  Insanity,  January,  1878,  p.  368. 


—  9  — 

after  admittance  to  the  asylum.  She  was  an  intelli- 
gent German  Jewess,  rather  below  the  medium  size, 
thirty  years  of  age,  hair  and  'complexion  light.  She 
was  then  thin  in  flesh,  pulse  weak,  hands  red  and 
cold,  lips  bluish,  tongue  pale  and  tremulous  when  ex- 
tended; but  few  of  her  teeth  remained,  and  her  face 
had  a  pinched  look;  her  smile  was  very  pleasant,  but 
her  expression  at  other  times  was  suspicious  and  irri- 
table." 

"  She  was  in  bed  suffering  from  what  seemed  to 
be  a  severe  attack  of  hsematemesis;  various  remedies 
were  applied,  but  the  hemorrhage  continued  several 
days  unabated.  Her  bodily  condition  continuing, 
however,  perfectly  good,  "notwithstanding  the  blood 
lost,  simulation  was  suspected;  treatment  was  sus- 
pended, and  the  bleeding  ceased.  The  coffee-ground 
appearance  of  ejected  matter  she  had  imitated  by 
vomiting  food  into  her  chamber-vessel  and  covering  it 
with  blood  (pricked  and  sucked  from  her  gums)  and 
urine.  This  attack  was  followed  by  others  of  hysteri- 
cal dysmenorrhoea  and  dysentery.  Toward  the  end  of 
the  month  she  became  much  depressed.  *  *  *  On  the 
25th  of  the  month,  in  a  paroxysm  of  despair,  she  broke 
twenty-three  panes  of  glass;  with  a  small  piece  of  glass 
she  cut  her  left  wrist,  and,  inserted  it  into  the  wound, 
endeavored  to  reach  the  arteries.  *  *  *  She  was  much 
agitated,  trembling  from  head  to  foot,  and  crying,  but 
however  said  nothing.  The  next  day  she  was  very 
repentant  for  what  she  had   done,  and  said  that  she 


would  never  try  to  do  it  again;  but  in  about  three 
weeks  she  again  became  'discouraged,'  to  use  her  own 
words,  or  depressed,  irritable,  and  suspicious,  and,  be- 
ing enraged  because  she  had  been  refused  opium,  cut 
her  arms  to  avenge  her  wrongs.  The  wounds  were 
immediately  below  the  elbow,  on  the  inner  surface  of 
the  forearm,  where  the  flexors  are  thickest.  One  cut 
was  six  inches  in  length,  the  other  four.  *  *  *  She 
was  crying,  and  endeavored  to  conceal  the  cuts  when 
seen,  and  would  say  nothing  as  to  the  situation  or 
number  of  pieces  of  glass  she  was  said  to  have  thrust 
into  the  wounds."  On  examination  under  ether, 
several  pieces  of  g'ass  were  found  in  the  wound  and 
removed.  Subsequently,  she  v^^ounded  herself  in  like 
manner  several  times,  with  the  result  of  finally  setting 
up  an  erysipelatous  inflammation,  which,  in  its  turn, 
was  followed  by  oedema  glottidis;  suffocation  appear- 
ing imminent,  tracheotomy  was  performed;  on  the 
eleventh  day  the  tube  was  removed,  and  the  wound 
healed  in  three  weeks  after  the  operation. 

For  some  time  subsequently  she  appeared  to  im- 
prove; but  after  a  time  the  mutilations  were  begun 
afresh  and  continued  more  or  less  frequently  until 
June,  1877,  when  she  cut  herself  for  the  last  time,  and 
soon  afterwards  "broke  her  chamber-vessel  to  pieces 
on  the  wall  over  her  head." 

"  The  following  is  a  list  of  articles  which  have 
been  removed  from  her  arms  and  saved:  ninety-four 
pieces  of  glass,  thirty-four  splinters,  two  tacks,   four 


shoe  nails,  one  pin,  one  needle.  Several  pieces  of 
glass,  and  the  pins  and  needles  first  removed,  were  un- 
fortunately mislaid  and  lost.  Including  these,  the 
whole  number  of  objects  removed  amounted  to  one 
hundred  and  fifty.  *  *  *  The  longest  splinter 
was  nearly  six  inches  long."     *     *     * 

"  Strange  as  it  seems,  she  apparently  experienced 
acute  erotic  pleasure  from  the  probings  which  she  was 
subjected  to."  *  *  *  u  gj^g  ^^g  ]^qq^  ^ery  hys- 
terical, having  frequent  attacks  of  choking,  globus 
hystericus,  and  imagined  at  one  time  that  she  had  a 
spool  in  her  throat,  and  could  only  swallow  through 
the  hole  in  the  middle." 

This  case  is  certainly  unique,  as  regards  the 
character  and  extent  of  self -mutilation  practised. 

Dr.  Channing  also  cites  the  case  reported  by  Dr. 
Robie,*  of  the  Dundee  Asylum,  in  which  an  hysteri- 
cal woman  swallowed  a  circular  tea-cady,  one  and 
one-fourth  inches  in  diameter,  with  suicidal  intent. 

Dr.  J.  B.  Andrews,  of  the  Utica  Asylum,  has  re- 
ported a  most  interesting  case,  in  which  he  removed 
three  hundred  needles  from  the  body  of  a  female  pa- 
tient. The  needles  had  all  been  inserted  before  she 
became  a  patient  in  the  asylum.  The  patient  was 
hysterical,  and  bore  a  strong  resemblance,  in  some  re- 
spects, to  the  case  of  Mrs.  Miller,  f 
•     Soon   after  the  introduction  of  anaesthetics,    an 


*Journal  of  Mental  Science  for  July,  1875. 

f Journal  of  Insanity  for  July,  1872;  quoted  bv  Channing. 


unusual  form  of  accusation  made  its  appearance  in 
court.  These  accusations  were  based  upon  the  allega- 
tions of  certain  women,  to  the  effect  that  they  had 
been  outraged  while  under  the  influence  of  an  anaes- 
thetic, in  the  office  of  a  physician  or  dentist.  Medico- 
legal literature  abounds  in  cases  of  this  character.* 
When  these  peculiar  charges  were  first  made  in  court 
there  can  be  little  doubt  that  gross  injustice  was  fre- 
quently done,  as  both  judge  and  jury  were  but  too  liable 
to  lend  undue  credence  to  the  women  declaring  them- 
selves aggrieved.  In  a  short  time,  however,  it  became 
evident  to  court  and  jurors  alike  that  the  women  who 
made  these  accusations  had  either  labored  under  some 
unusual  mental  aberration,  incident  to  the  inhalation 
of  the  anaesthetic,  or  were  the  victims  of  some  form  of 
neurosis.  It  was  natural,  under  these  circumstances, 
that  the  thoughts  of  medical  witnesses  should  revert 
to  hysteria;  and  accordingly,  at  the  present  day,  the 
connection  of  this  insiduous  affection  with  many  cases 
of  this  kind  has  been  clearly  made  out. 

The  following  are  evidently  cases  in  point:  "  In 
1854  a  clergyman's  sister  came  to  my  office  for  the 
purpose  of  taking  ether  and  having  a  tooth  extracted. 


*Vide  "  Medical  Jurisprudence  "  of  Wharton  and  Stille. 

"Artificial  Anaesthesia  and  Anaesthetics,"  by  Henry  M. 
Lyman,  A.M.,  M.D.,  etc.  New  York:  William  Wood  &  Co., 
1881.     Also 

"A  Manual  of  Medical  Jurisprudence,  by  Allan  McLane 
Hamilton,  M.D.,  Birmingham  &  Co.,  New  York,  1883. 


—  13  — 
and  brought  her  brother's  wife  with  her.  I  began  to 
administer  the  ether  to  the  patient,  and  whilst  renew- 
ing it  she  got  away  from  me,  and  seemed  alarmed  and 
offended.  I  did  not  attempt  to  compel  her  to  breathe 
any  more  ether,  but  urged  her  to  take  it,  and  so  also 
did  her  brother's  wife;  but  she  would  take  no  more; 
she  had  the  impression,  so  her  brother  told  me,  that  I 
attempted  to  violate  her,  and  that  his  wife  assisted 
me.  It  was  a  long  time  afterward  before  she  would 
fully  give  up  that  she  was  mistaken  in  the  matter."* 

The  following  case  is  quoted  by  Lyman  :f  "A 
case  of  the  utmost  importance  to  the  whole  profession, 
not  in  Great  Britain  only,  but  everywhere,  was  tried 
before  Mr.  Justice  Hawkins,  at  the  assizes  at  North- 
ampton, on  the  9th  of  November.  It  was  a  charge 
against  a  surgeon's  assistant  of  criminal  assault — of 
rape  upon  a  patient  when  under  the  influence  of 
chloroform.  If  there  is  a  dastardly  crime,  it  is  to  take 
advantage  of  a  woman's  helpless  unconsciousness  to 
violate  her  person.  And  so  the  magistrate  thought, 
who  sent  the  accused  to  jail  on  the  14th  of  September, 
declining  to  hear  anything  in  his  favor,  and  resolutely 
refusing  to  accept  bail.  The  charge  was  that  a  mar- 
ried woman,  named  Child,  went  to  the  surgery  of  her 
family  medical  attendant  to  have  her  teeth  operated 


*Dr.  N.  L.  Folsom,  in  the  Med.  and  Surg.  Reporter  for 
January  12,  1877.     Quoted  by  Dr.  Lyman,  op.  cit.,  p.  95; 

fContained  in  the  Philadelphia  Medical  Times  for  De- 
cember 22,  1877. 


—   14  — 

upon.  She  had  been  there  a  day  or  two  before,  but 
the  attempt  to  put  her  under  chloroform  had  failed. 
A  second  attempt  was  rather  more  successful.  She 
evidently  had  some  peculiar  idiosyncrasies  in  relation 
to  chloroform,  for  he  gave  it  for  an  hour,  and  yet  she 
was  never  sufficiently  under  its  influence  to  admit  of 
the  operation  being  performed.  She  was  accompanied 
by  a  friend — a  Miss  Fellows.  At  the  end  of  an  hour 
Miss  Fellows  went  out  of  the  room  and  saw  Mr.  Child. 
In  a  quarter  of  an  hour  Miss  Fellows  returned.  The 
prosecutrix  maintained  that  on  Miss  Fellows'  return 
she  was  quite  conscious,  but  unable  to  speak.  Find- 
ing it  impossible  to  perform  the  operation,  the  accused 
accompanied  the  prosecutrix  and  her  friend  home. 
So  far  Mrs.  Child  had  been  unable  to  speak,  but 
shortly  after  the  accused  left  the  house  she  complained 
to  her  husband  that  he  had  taken  advantage  of  the 
absence  of  Miss  Fellows  to  assault  her  criminally. 
Next  day,  when  the  accused  called,  he  was  told  about 
what  she  had  said,  and  he  replied  that  she  was  labor- 
ing under  a.delusion.  Under  cross-examination,  Mrs. 
Child  said  that  she  told  the  accused  that  if  he  would 
admit  the  offense  and  quit  the  town  (Birmingham) 
she  would  forgive  him.  This  the  accused  declined  to 
do,  denying  that  he  had  committed  any  offense.  He 
was  then  given  into  custody.  The  prosecutrix  stated 
that  the  offense  was  perpetrated  immediately  after 
Miss  Fellows  left  the  room,  that  the  prisoner  went 
upon  his  knees  and  then  assaulted  her.     Miss  Fellows 


—  In- 
stated that  on  her  return  she  found  Mrs.  Child  in  pre- 
cisely the  same  position  in  the  chair  which  she  occu- 
pied when  she  went  out  of  the  room.  Such  were  the 
facts  of  the  case.  *  *  *  j^  ^^g  meantime  the  un- 
fortunate surgeon's  assistant  was  sent  to  prison. 

"  When  the  case  came  to  be  tried,  a  large  number 
of  medical  men  of  repute  came  forward  voluntarily  to 
aid  the  accused's  defence,  and  did  this  quite  gratui- 
tously."* 

A  number  of  cases  were  related  by  medical  wit- 
nesses, in  which  females,  undergoing  operations  at  the 
hands  of  dentists  and  surgeons,  had  alleged  that  they 
had  been  criminally  assaulted,  persisting  in  this  belief 
in  some  cases  for  years  afterwards. 

Finally,  the  judge  demanded  of  the  jury  whether 
it  was  necessary  to  sum  up,  and  they  replied  it  was 
unnecessary;  they  were  already  agreed  upon  a  verdict 
of  acquittal.  "  Mr.  Justice  Hawkins  pointed  out  that 
such  a  verdict  would  not  be  the  slightest  imputation 
upon  the  absolute  sincerity  of  the  prosecutrix,  who,  no 
doubt,  firmly  believed  every  word  of  what  she  had 
said.  He  then  congratulated  the  accused  upon  hav- 
ing had  an  opportunity  of  fully  vindicating  himself 
upon  the  charge  preferred,  and  said  that  the  verdict 
of  acquittal  did  not  mean   that  there  was  insufficient 


*Among  these  witnesses,  was  the  celebrated  Dr.  B.  W. 
Richardson,  to  whose  testimony  the  subsequent  acquittal  of  the 
accused  was  in  great  measure  attributable. 


—  i6  — 

evidence,  but  that  the  accused  was  entirely  cleared  of 
any  imputation  in  respect  to  the  charge  preferred 
against  him.  *  *  *  The  accused  was  then  dis- 
charged from  custody,  having  been  in  prison  two 
months  for  no  offence." 

It  is  a  common  belief  among  certain  persons  that 
the  mental  phenomena  recorded  above  are  due  to 
some  extraordinary  effect  of  the  anaesthetic.  But  it  is 
a  noteworthy  circumstance  that  such  cases  are  usually 
observed  among  neurotic,  hysterical  females,  or  among 
those  in  whom  there  is  a  strong  erotic  tendency.  A 
certain  constitutional  predisposition  seems,  therefore, 
a  pre-requisite  in  all'such  cases.  There  can  be  little 
doubt  that  such  an  hysterical  predisposition  was  pres- 
ent in  the  foregoing  case,  though  the  clinical  history 
is  somewhat  incomplete  on  this  point. 

When  such  instances  occur,  diligent  inquiry  should 
always  be  made  regarding  the  family  history.  The 
discovery  of  the  existence  of  consanguineous  insanity, 
or  the  affirmation  of  witnesses  that  the  prosecutrix  is 
of  a  "  nervous,"  hysterical  disposition,  should  be  ac- 
cepted, in  the  absence  of  other  more  positive  testi- 
mony, as  proof  positive  of  the  innocence  of  the  ac- 
cused. In  our  estimation  the  verdict  rendered  in  the 
case  above  cited  was  most  just  and  in  entire  harmony 
with  the  most  enlightened  scientific  opinion. 

Fictitious  attempts  at  suicide  are  a  favorite  means 
of  attaining  sympathy  among  hysterical  women.  An 
instance  of  this  kind  came  under  my  immediate  notice 


—  17  — 

but  a  few  weeks  since.     The  history  in  brief  was  as 
follows: 

Mrs.  C,  a  young  woman  of  apparently  robust 
constitution,  had  been  married  but  two  years,  when 
she  became  feverish  and  restless,  complaining  that, 
ever  since  the  birth  of  her  child,  she  "  had  not  been 
the  same  woman."  She  also  developed  the  idea  that 
her  husband  was  faithless  in  his  marital  relations,  al- 
though the  latter  gave  constant  and  convincing  proof 
of  his  affection.  Her  constant  complaining,  and  al- 
ternate weeping  and  laughter,  caused  such  pain  and 
annoyance  to  those  about  her  that  the  family  physician 
was  consulted  on  several  occasions  with  regard  to  her 
condition.  On  hearing  that  her  medical  adviser  had 
expressed  the  opinion  that  she  was  a  sufferer  from 
hysteria,  and  that  her  sufferings  were  purely  the  pro- 
duct of  the  imagination,  she  became  very  angry,  and 
declared  that  she  was  the  victim  of  a  "plot."  Soon 
afterwards,  while  the  family  were  sitting  at  table,  she 
suddenly  appeared  m  the  room,  and  declared  that  she 
had  taken  poison,  exhibiting,  in  corroboration  of  her 
assertion,  a  vessel  containing  a  quantity  of  finely- 
powdered  glass.  During  the  scene  of  consternation 
which  succeeded  this  tragic  announcement,  she  pre- 
served an  imperturbable  exterior,  and  seemed  rather 
gratified  than  otherwise  at  the  sorrow  depicted  upon 
the  countenances  of  those  about  her.  When,  however, 
the  hastily  summoned  medical  attendant  proposed  the 
administration  of  an   emetic,   and   at  the  same  time 


—   i8   — 

made  preparations  to  introduce  the  tube  of  a  stomach 
pump,  she  protested  vigorously,  by  word  and  action, 
biting  and  scratching  those  who  attempted  to  restrain 
her.  Finding,  however,  that  her  strength  was  failing, 
and  that  she  was  about  to  be  overpowered,  she  confess- 
ed that  she  had  not  yet  swallowed  the  broken  glass,  but 
was  about  to  do  so  in  the  presence  of  the  family,  in 
order  that  her  loss  might  be  more  "appreciated." 

Such  cases  are  common  enough  in  practice,  and 
when  the  previous  history  of  the  patient  is  accessible, 
they  need  cause  but  slight  embarrassment. 

It  would  be  possible  to  multiply  histories  of  like 
character,  growing  out  of  a  morbid  desire  for  notoriety 
and  sympathy,  almost  ad  infinititm.  Medical  and  legal 
literature  abound  in  cases  of  this  kind.  Without 
pursuing  the  subject  further,  however,  we  will  content 
ourselves  with  stating  that  such  instances  are  by  no 
means  confined  to  the  female  sex,  but  are  found  to 
prevail  among  men,  though  to  a  less  extent  than 
among  women. 

Besides  the  more  pronounced  mental  phenomena 
exhibited  by  hysterical  persons,  which  the  foregoing 
description  and  cases  have  served  to  display,  individ- 
uals of  this  class  are  subject  to  various  other  forms  of 
psychical  disturbance. 

One  of  the  most  distressing  mental  symptoms 
found  in  the  hysterical  consists  in  a  persistent  morbid 
impulse  to  commit  some  act  of  violence.  The  objects 
of  such  morbid  impulses  are  usually  found  among  the 


—  19  — 
immediate  friends  or  family  connections  of  the  patient. 
Thus  I  was  consulted  recently  by  a  German  as  to  the 
mental  condition  of  his  wife,  who  had  caused  great 
uneasiness  by  announcing  that  she  was  afraid  to  re- 
main alone  with  her  children,  as  she  had  an  uncon- 
trollable impulse  to  "throw  them  out  of  the  window.'' 
She  also  begged  her  husband  to  remove  a  revolver, 
which  he  was  in  the  habit  of  placing  under  his  pillow 
at  night,  as  she  declared  that  she  felt  an  almost  resist- 
less impulse  to  take  the  weapon  and  "  shoot  him  in  his 
sleep."  Her  general  mental  condition  was  described 
as  "nervous,"  by  which  was  meant  that  she  was  fretful, 
feverish,  and  lachrymose.  In  appearance  she  is  stout 
and  healthy,  and  the  only  derangement  in  bodily  func- 
tion is  an  occasional  attack  of  dysmenorrhoea. 

This  morbid  explosiveness,  this  tendency  to  com- 
mit acts  of  violence,  frequently  finds  expression  in  the 
destruction  of  inanimate  objects.  This  form  of  men- 
tal disturbance  is  prevalent  among  young  girls  of  hys- 
terical tendencies.  Instead  of  the  irritable  and  ex- 
plosive tendencies  finding  vent  in  violent  conduct 
toward  individuals,  the  destructive  impulses  are  di- 
rected towards  the  inanimate  environment.  The  bed 
clothes  are  torn  into  shreds  ;  tapestries  are  pulled 
down  ;  the  clothing  is  thrown  about,  and  the  furniture 
broken  in  pieces.  Sometimes  the  house  is  set  on  fire,  and 
the  most  incredible  intrigues  concocted  against  friends 
and  acquaintances.  In  many  instances,  as  we  have 
seen,  the  subject  seeks  to  gain  sympathy  and  notoriety 


by  her  extraordinary  conduct ;  and  to  attain  this  end 
she  does  not  hesitate  to  lie,  defame  at,  or  even  commit 
murder.  On  the  other  hand,  in  not  a  few  cases,  it  is 
utterly  impossible  to  ascertain  the  slightest  motive  for 
the  commission  of  the  various  heinous  crimes  of  which 
the  hysterical  are  guilty.  Sometimes  the  duplicity  of 
hysterical  women  is  so  profound  as  to  baffle  the  efforts 
of  the  most  expert  medical  witnesses.  As  a  conse- 
quence, the  ends  of  justice  are  frequently  perverted, 
and  on  more  than  one  occasion  perfectly  innocent  per- 
sons have  suffered  at  the  hands  of  the  law  for  crimes 
which  have  subsequently  been  shown  to  be  the  acts  of 
hysterical  females.  From  what  has  been  said,  it  is 
evident  that  the  medico-legal  relations  of  hysteria  are 
of  the  utmost  interest  and  importance.  Were  this  the 
proper  occasion  an  entire  chapter  could  well  be  de- 
voted to  this  branch  of  the  subject  ;  but  as  such  a 
digression  would  evidently  transcend  the  scope 
of  the  present  work  we  must  content  ourselves 
with  referring  to  the  excellent  book  of  Legrand  du 
Saulle,*  and  the  more  recent  little  work  of  Dr.  Allan 
McLane  Hamilton,  which  certainly  constitutes  a  valu- 
able contribution  to  legal  medicine. 

Hysteria  is  frequently  complicated  with  mental 
disturbances  of  such  profundity  as  to  constitute  a  ver- 
itable "insanity."  By  this  we  mean  that  the  psychi- 
cal disturbances  attain  the  gravity  of  mania  or  melan- 


■^Les  Hysteriques  etat  physique  et  etat  mental,  etc.,  par 
le  Dr.  Legrand  du  Saulle,  Paris,  1883. 


cholia,  with  sexual  or  uterine  symptoms,  feigned  bod- 
ily affections  and  other  deceptions,  practiced  with  a 
view  to  obtain  sympathy;  and  a  morbid  irascibility 
and  erotomany.  The  erotic  tendencies  may  be  con-  ^ 
cealed  at  first ;  but  careful  interrogation  and  observa- 
tion almost  invariably  end  in  their  discovery. 

The  threats  and  abortive  attempts  at  suicide  re- 
sorted to  by  the  patient  have  usually  little  significance, 
and  rarely  result  in  grave  consequences.  Hysterical 
convulsions  and  retention  of  urine,  of  which  we  shall 
take  occasion  to  speak  later,  are  sometimes  present. 

Sometimes  the  diagnosis  of  this  form  of  mental 
derangement  presents  peculiar  difficulties,  and  there 
is  great  liability  of  confounding  it  with  masturbational 
and  "adolescent"  insanity.  The  most  we  can  do 
when  doubts  of  this  character  arise  is  to  postpone  a 
definite  verdict  until  all  the  facts  in  the  case  are  thor- 
oughly known.  We  should,  moreover,  guard  against 
pronouncing  a  case  one  of  hysterical  insanity  until  we 
have  become  thoroughly  convinced  that  the  hysterical 
symptoms  constitute  its  most  prominent  feature. 

Of  hysterical  insanity  Clauston  observes  :  "  The 
fasting  girls,  the  girls  with  stigmata,  those  who  see 
visions  of  the  Saviour,  and  the  saints,  and  receive 
special  messages  in  that  way,  the  girls  who  give  birth 
to  mice  and  frogs,  and  those  who  live  on  lime  and 
hair,  are  all  cases  of  this  disease."* 

*0p.  cit.,  p.  331  - 


The  following  case,  quoted  from  Clauston,  is  a 
fair  illustration  of  hysterical  insanity  :  "  J.  U.,  age 
21,  of  nervous  and  excitable  temperament;  habits 
correct.  An  epileptic.  Had  on  one  occasion  at 
home  a  mild  attack  of  what  must  have  been  sub-acute 
maniacal  excitement.  The  cause  of  the  present  attack, 
which  had  lasted  for  four  days,  was  a  fright  which  first 
produced  ordinary  hysterical  symptoms,  and  then 
maniacal  symptoms  engrafted  on  them.  She  shouted 
and  screamed,  and  spoke  of  hearing  God  speaking  to 
her,  and  would  rush  to  the  window  to  jump  out.  She 
imagined  she  was  a  most  important  person,  attitudin- 
ized, and  did  everything  to  attract  attention  to  her- 
self. Attention  and  sympathy  were  craved  by  her, 
and  if  she  could  not  get  them  in  one  way  she  tried 
another.  She  refused  her  food,  saying  it  was  pois- 
oned, but  took  it  rather  than  be  fed  with  the  stomach 
pump.  She  had  raenorrhagia,  and  was  most  mi- 
nute and  circumstantial  in  the  details  as  to  her 
health.  She  was  tried  with  hyoscyamine,  valerian, 
and  monobromide  of  camphor,  with  apparent  benefit  ; 
but  I  consider  the  greatest  improvement  was  produced 
in  her  case  by  discipline,  work,  open  air  exercise,  ton- 
ics, and  good  plain  food  in  abundance.  She  improved 
at  first,  and  once  or  twice  relapsed,  but  in  two  months 
she  recovered  and  was  discharged.  I  do  not  like  to 
keep  hysterical  cases  too  long  in  the  asylum  after  con- 
valescence, as  a  general  rule,  for  they  sometimes  get 
too  fond  of  the  place,  preferring  the  dances,  amuse- 


—  23  — 
ments,  and  general  liveliness  of  asylum  life,  even  with 
its  restrictions,  to  the  humdrum  and   hard   work   of 
poor  houses."* 

The  following  is  an  exceedingly  characteristic  let- 
ter of  a  maniacal  hysterical  girl,  and  seems  to  illus- 
trate in  a  striking  manner  the  morbid  psychology  of 
the  subject :  f 

"  My  Dear  Mamma — It  is  time  that  I  leave  to  re- 
turn home.  I  have  been  tremendously  changed  for 
the  better.  I  think  papa  will  be  able  to  get  me  a  com- 
mission under  Garibaldi  before  long.  There  are  three 
to  whom  I  am  especially  indebted — one  Mr.  C,  the 
modeller,  the  other,  the  doctor,  a  eunuch  who  mod- 
elled me  at  the  fire  and  attended  me  and  bathed  me. 
He  is,  I  am  sure,  a  gentleman,  a  splendid  doctor. 
Could  not  papa  get  him  into  a  regiment  abroad? 
And  there  is  the  nurse.  Could  not  papa  get  him  a 
situation  away  from  Morningside  Asylum,  where  I  am 
at  present  ?  I  should  like  papa  to  come  for  me  as 
soon  as  possible.  Do  you  remember  the  verse,  "  There 
are,"  etc.  (12th  verse,  ix.  chapter  of  Matthew)  about 
eunuchs  ?  Then  I  beg  to  inform  you  that,  according 
to   Scripture  and  my  conscience,  Jessy,  your  cook,  is 


*" Clinical  Lectures  on  Mental  Diseases,"  by  T.  S.  Claus- 
ton,  M.  D..  etc.,  Philadelphia,  1884. 

f Taken  from  the  "  Morosonian  Lectures,"  by  Drs.  Skaal 
and  Clauston,  for  1873,  Journal  of  Mental  Science"  vol.  xix, 
p.  500;  vide  also  "Clinical  Lectures  on  Mental  Diseases,"  by 
T.  S.  Clauston,  Philadelphia,  1884-1885,  p.  341. 


—    24   — 

a  man  ;  and  Janet,  the  mad  devil,  is  a  man  ;  and  D. 
and  H.,  boys,  who  can  have  children.  Aunt  I.  is  a 
man,  and  yourself  also,  both  made  of  men,  and  I  am 
a  boy,  made  of  Dr.  C.  and  Dr.  Z.  Mrs.  T.  is  a  man 
made  of  men.  They  are  very  ignorant  on  this  sub- 
ject here  ;  but  as  for  me,  it  is  certain  that  at  least  the 
spirits  have  shown  me,  which  Christ  sent  me  when  I 
was  under  drugs  ;  they  showed  me  this.  I  have  at 
times  since  I  come  here  passed  the  shadows  of  death, 
and  therefore  am  authorized  to  speak  in  opposition  to 
all  men  and  women,  gentlemen  and  ladies,  who  oppose 
me.  I  am,  I  can  swear,  as  you  want  to  know  what  sex 
I  belong  to,  a  mixture  of  a  nymph  and  a  half  man, 
half  woman  and  a  boy,  and  a  dwarf,  and  a  fairy.  I 
know  more  than  my  fellow  mortals,  have  expired 
eleven  times  before  the  time. — I  am,  etc." 


CHAPTER  111. 

SENSORY  DISORDERS— HYPER/ESTHESIA. 

Hyperaesthesia  is  an  almost  invariable  accompani- 
ment of  hysteria,  and  may  involve  a  portion  or  all  of 
the  special  senses.  Sometimes  there  is  an  abnormal 
increase  in  the  acuteness  of  the  perceptive  faculties; 
so  that  it  is  a  subject  of  common  remark,  even  among 
the  laity,  that  hysterical  persons  see,  hear,  smell,  and 
taste  with  greater  keenness  than  those  in  health. 
Again  there  may  be  a  certain  degree  of  sensory  per- 
version, manifested  by  a  dislike  for  certain  stimuli 
which  by  the  healthy  are  looked  upon  with  indiffer- 
ence or  even  regarded  as  pleasurable.  Or  there  may 
exist  a  positive  liking  for  sensations  which,  to  the 
majority  of  mankind,  are  regarded  with  feelings  of 
repugnance. 

Coupled  with  these  anomalies  of  sensation,  there 
exists,  in  the  majority  of  cases,  a  corresponding  per- 
version of  the  higher  mental  faculties — a  veritable 
'■''psychical  hypercBsthesia,"  as  Jolly  calls  it.  We  have 
already  discussed  the  various  mental  disorders  of  the 
affection,  which  may  properly  be  comprised  under  this 
heading,  in  the  previous  paragraph,  and  therefore  ab- 
stain from  further  particularization  on  the  present 
occasion.  Coeval  with  these  sensory  disturbances, 
certain  anomalies  of  perception  appear,  which,  in  the 
absence  of  all  primary  excitement  of   the  peripheral 


—    26    — 

apparatus,  cannot  be  regarded  otherwise  than  as 
purely  subjective.  It  is  thus  that  the  true  hallucina- 
tions of  hysteria  originate — phenomena  which  un- 
questionably lie  at  the  root  of  the  illusions  and  delu- 
sions of  the  more  serious  mental  complications  of  the 
affection. 

Perversion  and  exaltation  of  the  senses  of  smell 
and  taste  are  especially  frequent.  The  subject  de- 
clares that  she  detects  odors  of  an  agreeable  or 
repugnant  nature,  which  remain  imperceptible  to  those 
about  her;  and  careful  investigation  shows  that  she 
really  is  able  to  discover  the  presence  of  astonishingly 
minute  quantities  of  semi-inert  substances.  With  this 
unusual  power  of  perception  there  is  often  marked 
sensory  perversion,  manifested  in  a  strong  dislike  for 
certain  substances  which  by  healthy  persons  are  con- 
sidered to  possess  an  agreeable  taste  or  odor.  Or  the 
process  is  reversed,  the  subject  expressing  herself  as 
delighted  with  the  odor  and  taste  of  the  most  disgust- 
ing substances.  Thus  a  lady  afflicted  with  hysteria 
confessed  to  me  that  the  odor  of  excrement  was 
agreeable  to  her;  while  another  patient,  a  young  girl, 
tells  me  that  the  odor  of  eau  de  cologne  excites  in  her 
feelings  of  the  liveliest  repugnance. 

Cases  exhibiting  a  decided  increase  in  the  acute- 
ness  of  the  sense  of  smell  are  found  in  the  literature 
of  the  subject,  and  are  by  no  means  as  rare,  according 
to  my  experience,  as  some  writers  appear  to  imagine. 
For  example,  the  lady  above  referred  to  declared  that 


—    27    — 

she  was  able  to  detect  the  presence  of  her  four-year- 
old  child  by  the  aid  of  the  sense  of  smell,  when  the 
latter  entered  unexpectedly  a  neighboring  apartment; 
and  a  hysterical  boy  whom  I  have  recently  seen  is 
able,  according  to  his  father,  to  appreciate  the  pres- 
ence of  a  dog  or  cat,  even  when  the  latter  are  at  some 
distance  and  totally  invisible.  Doubtless  similar  in- 
stances will  occur  to  most  physicians  of  extended  ex- 
perience. 

When  hallucinations  of  smell  and  taste  exist  in 
complicated  cases,  they  are  said  to  particularly  facili- 
tate the  establishment  of  more  or  less  permanent 
delusions.* 

I  cannot  say  that  my  own  experience  agrees  en- 
tirely with  the  foregoing,  since  I  have  found  that 
hallucinations  of  other  senses,  particularly  those  of 
hearing,  are  quite  as  prolific  of  erroneous  ideas  as 
those  of  smell  and  taste. 

Hyperaesthetic  conditions  of  the  organ  of  sight 
are  frequently  met  with.  Sometimes  the  subject  com- 
plains that  bright  light  is  disagreeable  to  her,  and 
resort  is  had  to  colored  spectacles,  which  may  afford 
apparent  relief.  In  other  cases  the  photophobia  is  so 
great  that  the  afflicted  women  seclude  themselves  in 
darkened  rooms  for  days  together,  refusing  food  ex- 
cept when  brought  to  them.  Sometimes  the  hyper- 
sensitiveness    is    only    apparent    in   connection  with 


*  Vide  Jolly  on  Hysteria,  op.  cit.,  p.  497. 


—    28    — 

certain  colors,  especially  red.  Subjective  sensations 
of  light,  assuming  the  form  of  spots,  flashes,  and 
sparks  are  also  observed.  In  some  cases,  the  subjec- 
tive appearances  attain  to  the  dignity  of  veritable  hallu- 
cinations, which  may  be  agreeable  or  repulsive  in 
character.  The  physiological  substratum  of  the  con- 
dition known  as  ecstacy  is  unquestionably  to  be  sought 
after  among  these  visual  hallucinations. 

Sometimes  the  subject  recognizes  the  subjective 
nature  of  many  of  these  impressions;  but  in  other 
cases  it  is  impossible  to  convince  her  of  the  unreality 
of  the  phenomena.  Under  the  latter  circumstances 
delusive  opinions  may  arise. 

In  some  cases  there  is  a  manifest  increase  in  the 
acuteness  of  vision,  which  is  not  to  be  accounted  for 
merely  on  the  score  of  a  prolonged  sojourn  in  a  dark- 
ened room.  The  extraordinary  narratives  of  the  vis- 
ual powers  of  hysterical  persons,  in  which  the  latter 
are  said  to  read  with  their  back  turned  or  with  closed 
eyes,  are  evidently  unconscious  perversions  of  the 
truth  or  gross  deceptions. 

The  sense  of  hearing  is  often  exaggerated  in  hysr 
terical  persons  to  such  a  degree  that  they  readily  ap- 
preciate sounds  which  are  imperceptible  to  healthy 
mdividuals.  So  sensitive  do  they  become  to  sound 
that  such  an  ordinary  occurrence  as  the  squeaking 
of  a  door,  the  rumbling  of  a  cart,  or  the  cry 
of  a  child  is  sufficient  to  cause  the  most  intense 
annoyance.     Subjective  sensations,   such    as  ringing. 


_    29    — 

blowing,  roaring,  humming,  and  singing  are  frequently 
encountered;  and  true  auditory  hallucinations  are  also 
met  with.  As  we  have  already  had  occas.on  to 
observe,  the  latter  frequently  result  in  establishment  of 
more  or  less  pronounced  mental  aberration. 

In  almost  all  cases  of  hysteria  there  is  present  a 
morbid  sensibility  to  pain.  This  exalted  susceptibility 
to  painful  impressions  may  be  confined  to  the  skin  or 
may  involve  the  more  deeply  seated  tissues.  It  is  sub- 
ject, moreover,  to  irregular  topographical  distributions. 
This  is  particularly  true  of  cutaneous  hypersesthesia, 
which,  though  sometimes  general — being  distributed 
over  the  entire  surface  of  the  body — is  often  confined 
to  certain  isolated  regions  of  the  integument.  Some- 
times the  skin  of  one  half  of  the  body,  or  one  or  more 
extremities,  or  of  certain  portions  of  the  trunk,  is  alone 
affected.  In  yet  other  cases  hyperaesthesia  and  anaes- 
thesia are  encountered  side  by  side,  or  at  all  events 
isolated  anaesthetic  islands  are  found  in  the  midst  of 
more  or  less  extended  hyperaesthetic  areas.  These 
curious  phenomena  certainly  constitute  a  most  enig- 
matical chapter  in  pathology;  but  it  would  be  a  practi- 
cal waste  of  time  to  examine  the  various  more  or  less 
ingenious  hypotheses  which  have  been  advanced  with 
a  view  to  their  explanation. 

When  the  cutaneous  hyperaesthesia  is  general,  the 
patient  suffers  great  torture  on  attempting  to  execute 
such  simple  movements  as  turning  about  in  a  chair  or 
dressing.     In  the  more  exquisite  cases,  the  mere  im- 


—  3°  — 
pact  of  the  bed-clothes  is  sufficient   to   cause   acute 
pain,  and  in  some  instances  convulsions. 

Besides  the  hypereesthetic  phenomena  above  re- 
ferred to,  almost  all  hysterical  individuals  complain  of 
pain,  which  may  be  diffuse  in  character  or  confined  to 
the  most  diverse  localities.  Sometimes  the  pain  is 
felt  over  the  entire  extent  of  the  abdomen,  and  may 
be  associated  with  tympanitis.  x\t  others  neuralgic 
pains  are  present  in  the  mammary  glands,  the  latter 
being  often  of  such  intensity  as  to  render  the  contact 
of  the  clothing  or  bed-linen  absolutely  unendurable. 
The  hyperaesthesia  is  particularly  marked  during  the 
menstrual  period.  Cardialgia  is  another  frequent 
symptom  of  hysteria,  and  one  which  is  often  associated 
with  more  or  less  persistent  vomiting — a  combination 
of  symptoms  which  may  give  rise  to  the  erroneous 
preconception  that  we  have  to  do  with  perforating 
ulcer  of  the  stomach.  This  impression  is  furthermore 
enhanced  by  the  fact  that  hysterical  females  are  often 
great  gourmands,  devouring  everything  set  before 
them  with  an  appetite  apparently  insatiable.  It  is  evi- 
dent that  such  persistent  gluttony  can  only  result  in. 
an  aggravation  and  perpetuation  of  these  digestive 
disturbances;  indeed,  I  am  not  sure  but  that  this  over- 
loading of  the  stomach  constitutes  the  starting  point 
of  many  of  the  gastric  disorders  to  which  the  hysteri- 
cal are  liable. 

Hysterical  persons  are  often  afflicted  with  an 
hyperaesthetic  condition  of  the  ovaries,   associated,   in 


—  31   — 

many  instances,  with  anaesthesia  of  the  same  side. 
At  the  same  time  they  complain  of  irritation  about  the 
external  genital  organs,  associated  with  a  morbid  in- 
crease of  sexual  excitement.  This  latter  condition, 
which  is  particularly  pronounced  at  the  time  of  men- 
struation, may  give  rise  to  reflex  spasm  of  the  sphincter 
muscle  ("  vaginismus  ")*  a  state  of  things  peculiarly 
unfavorable  to  coitus.  Owing  to  the  irritated  condi- 
tion of  the  urethra  and  bladder,  which  is  an  almost 
constant  concomitant,  the  desire  to  urinate  is  frequent, 
and  the  act  is  rarely  accomplished  without  consider- 
able pain. 

Dorsal  pain  is  a  more  or  less  frequent  accompani- 
ment of  hysteria.  Sometimes  it  is  situated  in  isolated 
spots  between  or  above  the  scapulae,  at  others  it  is  dis- 
tributed in  a  more  or  less  continuous  band  along  the 
course  of  the  vertebral  column  {spinal  irritation).  In 
the  more  exquisite  cases  the  slightest  pressure  above 
the  vertebrae  is  sufficient  to  cause  severe  pain,  while 
the  passage  of  the  wire-brush,  with  a  moderate  cur- 
rent, along  the  spine  is  sufficient  to  reveal  the  presence 
of  hyperaesthetic  spots,  in  the  less  severe  cases.  Sensi- 
tiveness of  the  uterus,  though  not  a  constant  symptom 
as  formerly  supposed,  is  frequently  met  with;  and 
while  doubtless  dependent,  in  some  instances,   upon 


*Vide  the  writings  of  Drs.  J.  Marion  Sims  and  T.  Gail- 
lard  Thomas;  also,  Axenfeld  et  Heuchard.  "  Traite  des 
nevroses,"  Paris,  1883. 


—  32  — 

uterine  disease,  must  in  man}-  other  cases  be  regarded 
as  of  purely  neurotic  origin. 

Thus  cases  of  uterine  pain  are  often  met  with  in 
those  who  have  been  treated  for  protracted  periods 
for  some  form  of  supposed  disease  affecting  the  uterus 
without  the  slightest  beneficial  result.  But  when 
placed  upon  the  back  and  treated  according  to  the 
system  of  spinal  rest  so  ably  advocated  by  Mitchell, 
they  often  display  astonishing  improvement  in  a  short 
space  of  time. 

Of  great  theoretic  and  practical  interest  are  the 
pains  occurring  about  the  joints  of  hysterical  persons 
pains  which  are  frequently  mistaken  for  symptoms  of 
true  articular  disease. 

To  Sir  Benjamin  Brodie*  has  been  ascribed  the 
credit  of  having  directed  the  attention  of  the  profes- 
sion to  the  frequency  of  these  enigmatical  symptoms. 

When  pressure  is  exercised  upon  the  joints  of 
those  affected  by  this  form  of  articular  neurosis, 
severe  pain  is  produced.  It  is  evident,  however,  that 
this  pain  is  located  in  the  soft  tissues  about  the  joint 
rather  than  in  the  latter,  since  the  forcible  apposition 


*Brodie,  Sir  Benjamin,  "  Lectures  Illustrative  of  Certain 
Local  Nervous  Affections,"  London,  1837.  Also  Esmarch, 
Ueber  "  Gelenkneurosen,"  1872.  Stromeyer,  "  Erf  ah  run  gen 
ueber  "  Localneurosen,"  Hanover,  1873.  Werner,  "Ueber 
Nervose  Coxalgie,"  Deutsche  Zeitschrift  fuer  Chirurgie,  Band 
L  Berger,  "  Zur  Lehre  von  den  Gelenkneuralgien,"  Berliner 
Klinische  Wochenschrift,  1883. 


—  33  — 

of  the  articular  surfaces  fails  to  produce  the  disagree- 
able symptoms  and  shock  peculiar  to  true  joint-dis- 
ease. Atrophy  of  certain  muscles  has  been  noted  by 
some  observers,*  after  the  affection  had  continued 
for  a  series  of  years.  It  is  probable,  however,  that 
the  attenuation  of  the  muscles  is  never  so  great  as  in 
organic  disease  of  the  joints. 

The  articulations  most  frequently  involved  are 
the  knee  and  hip  joints,  but  even  the  smaller  joints  of 
the  wrists,  ankles  and,  fingers  are  sometimes  af- 
fected. 

It  is  evident  that  an  accurate  diagnosis  in  cases 
of  this  kind  is  of  the  utmost  importance,  since,  if  the 
affection  be  mistaken  for  true  joint  trouble,  the  patient 
is  liable  to  all  the  inconvenience  arising  from  pro- 
longed antiphlogistic  and  orthopaedic  treatment.  Be- 
fore delivering  a  final  opinion,  therefore,  the  patient 
should  be  subjected  to  a  rigorous  physical  examina- 
tion. At  the  same  time  the  most  searching  inquiry 
should  be  instituted  regarding  her  general  physical 
and  mental  health,  with  a  view  to  discovering  any  in- 
dications of  hysteria  or  other  neurotic  trouble.  Not 
until  we  have  exhausted  the  last  resources  of  investi- 
gation are  we  justified  in  forming  a  definite  conclusion 
as  to  the  nature  of  the  affection. 


*Vide  "Nervous  Mimicry  of  Organic   Disease,  by  Dr.  J. 
Paget.     The  Lancet,  Vol.   II.     1873. 


—  34  — 

The  following  cases  reported  by  Skey*  are  fair 
illustrations  of  these  joint  affections: 

"Annie   W ,  aged    twenty-two,  was  admitted 

into  Treasurer's  Ward  in  the  spring  of  last  year.  She 
had  been  confined  to  her  bed  for  twelve  months,  and 
was  sent  up  from  her  parish,  near  Bedford.  During 
twelve  months  she  had  been  totally  deprived  of  motor 
power  in  the  left  leg,  and  during  ten  months  in  the 
left  arm.  The  two  extremities  lay  on  the  bed  perfect- 
ly motionless  and  paralytic.  Indeed,  her  case  was  re- 
ported to  me  as  one  of  hopeless  and  incurable  palsy. 
There  was  something  strange  in  the  girl's  aspect,  and 
in  the  total  absence  of  motor  power  extending  to  the 
toes.  A  truly  paralytic  limb  is  rarely  so  dead  as  these 
limbs  were;  we  can  often  obtain  some  sligh  manifesta- 
tion of  volition,  even  though  in  the  slightest  motion 
of  one  or  more  of  the  toes.  In  this  case  there  was  ab- 
solutely none  detectable  to  the  eye.  I  suspected  it  to 
be  a  case  of  hysteria,  and  ordered  her  valerian  and 
ammonia  in  full  doses  after  the  first  three  days;  meat 
diet  and  porter.  In  four  days  movement  on  voli- 
tion was  perceptible  in  all  the  toes  and  in  the  hand. 
In  a  fortnight  she  could  move  her  arm  and  leg  slowly 
in  all  directions.  In  one  month  she  walked  on 
crutches  about  the  ward,  and  in  six  weeks  she  left  the 
hospital  convalescent." 


*  "  On  Hysterical  Affections  of  the  Joints,"  by  Frederic 
C.  Skey.  F.  R.  S.      The  Lancet,  March  12,  1859. 


—  35  — 

The  history  of  the  above  case  is  not  as  complete 
as  might  be  desired;  but  the  following  instance,  quoted 
from  the  same  author,  is  more  to  the  point: 

"  Eliza  J ,  aged  twenty-two,  was  admitted  in- 
to Treasurer's  Ward  in  April  last  with  an  affection  of 
the  knee,  which  incapacitated  her  for  movement  of 
any  kind  on  the  affected  limb.  The  joint  was  scarcely 
perceptibly  swollen,  yet  she  could  not  bear  the  most 
superficial  examination  by  the  hand  without  an  ex- 
pression of  pain  quite  disproportionate  to  the  apparent 
amount  of  disease.  The  temperature  of  the  joint  was 
slightly,  but  not  much,  increased.  The  only  explana- 
tion obtainable  from  the  girl's  statement  referred  the 
injury  to  a  fall  six  weeks  prior  to  her  admission,  and 
three  weeks  before  the  first  appearance  and  even  the 
suspicion  of  disease.  During  the  interval  of  the  first 
three  weeks,  she  "  thought  the  joint  felt  occasionally 
more  stiff  than  usual."  This  girl  had  a  somewhat 
florid  complexion;  she  had  a  weak  pulse,  and,  as  almost 
a  matter  of  course,  had  cold  feet  and  severe  headaches. 
Both  sides  of  the  joints  bore  marks  of  previous  treat- 
ment in  the  form  of  pretty  active  scarifications.  It 
appeared  that  blood  had  been  taken  from  the  joint  by 
cupping  on  two  occasions,  to  the  extent,  as  nearly  as  I 
could  learn,  of  about  twelve  ounces;  and  a  blister  of 
some  magnitude  had  been  applied  on  its  front  surface. 
From  these  remedies  I  could  not  ascertain  that  any 
benefit  had  been  derived  to  the  affected  knee,  and  she 
thought,  on  the  whole,  her  attacks  of.  headache  had 


-  36  - 

been  more  frequent  and  severe.  Her  bowels  were 
habitually  constipated.  I  ordered  her  the  local  appli- 
cation, for  three  or  four  consecutive  nights,  of  a  lini- 
ment composed  of  two  drachms  of  the  fluid  extract  of 
opium  to  an  ounce  of  compound  soap  liniment,  and 
the  joint  to  be  rolled  with  flannel;  twice  a  day  a 
draught  of  ammonia  and  valerian;  full  diet  with  a  pint 
of  porter  daily.  The  local  application  was  continued 
with  intervals,  for  eight  or  nine  days,  with  much  re- 
lief and  without  return  of  pain.  At  the  expiration  of 
a  fortnight  the  medicine  was  changed  to  eight-grain 
doses  of  ferro-citrate  of  quinine,  and  she  left  the  hos- 
pital in  five  days  convalescent."* 


*  Other  contributions  to  the  literature  of  the  subject  are: 
"  Nervous  Mimicry  of  Organic  Diseases,"  by  Sir.  James  Paget, 
The  Lancet,  Nov.  i,  1873.  "  Paralysie  hysterique,  attitude 
vicieuse,  pied  bot  consecutif,"  by  N.  Damaschino,  Gazette  des 
Hopitaux,  1879,  P-  5^-  "Diseases  of  the  Nervous  System," 
Lecture  on,  by  Francis  E.  Anstie,  M.  D.,  The  Lancet,  1873, 
Nol.  I.,  pp.  437- 


CHAPTER  IV. 

SENSORY     DISORDERS     CONTINUED.  —  ANAES- 
THESIA. 

AncBsthesia. — Sensibility  is  frequently  diminished 
or  even  entirely  lost  in  hysteria.  Sometimes  the  an- 
aesthesia is  circumscribed  in  character,  as  we  have 
already  had  occasion  to  observe,  whereas  in  a  certain 
per  cent,  of  cases  it  may  involve  the  greater  portion 
of  the  integument,  and  even  extend  to  the  muscles 
and  other  deep-seated  tissues.  Nor  do  the  nerves  of 
special  sense  escape;  but,  on  the  contrary,  as  we  shall 
presently  see,  their  implication  often  gives  rise  to  pro- 
nounced functional  impairment.  Cutaneous  anaes- 
thesia usually  appears  after  an  hysterical  attack,  and 
is  liable  to  aggravation  from  subsequent  seizures. 
The  anaesthesia  thus  induced  exhibits  certain  ambli- 
tory  characteristics  of  a  most  interesting  nature  from 
a  clinical  standpoint.  Thus,  after  a  fresh  attack,  the 
anaesthesia  may  apparently  disappear;  but,  on  careful 
examination,  other  parts  are  found  to  be  affected.  Or, 
the  previously  anesthetic  portions  of  the  integument 
may  become  hyperaesthetic. 

Sometimes  tactile  and  thermic  sensibility  as  well 
as  sensibility  to  pain  are  impaired  or  lost;  but  as  a 
rule  the  capacity  to  appreciate  pain  is  alone  affected. 
The  distribution  of  the  anaesthesia  is  subject  to  great 


variation.  In  a  considerable  number  of  cases  it  is 
situated  on  the  dorsal  aspect  of  the  hands  and  feet;  in 
another  category  of  patients  one  or  more  limbs  are  in- 
volved, whereas  in  a  small  per  cent,  of  cases  it  is 
limited  to  one-half  of  the  body.  Anaesthesia  of  the 
entire  integument  is  least  frequently  met  with. 

Anesthesia  of  the  various  mucous  membranes  is 
frequently  encountered,  and  gives  rise  to  a  variety  of 
secondary  phenomena.  Thus,  if  the  nasal  mucous 
membrane  be  anaesthetic,  irritating  substances  and 
tickling  fail  to  cause  sneezing.  If  the  conjunctiva 
be  affected  it  may  be  touched  and  irritated  by  foreign 
substances  without  giving  rise  to  a  flow  of  tears  or 
reflex  spasm.  In  anaesthesia  of  the  pharynx  and 
adjacent  parts,  the  membrane  in  question  may  be 
titillated  and  otherwise  irritated  without  giving  rise  to 
vomiting;  and  if  the  loss  of  sensibility  be  very  exten- 
sive, taste  and  smell  may  be  abolished.  That  the 
bladder  and  rectum  may  sometimes  be  involved  seems 
probable  from  the  fact  that  they  are  sometimes 
greatly  distended  by  the  accumulation  of  feces  and 
urine,  a  condition  which  causes  the  patient  no  appre- 
ciable discomfort. 

The  mucous  membrane  of  the  vulva  and  vagina  is 
frequently  profoundly  anaesthetic.  It  is  this  condition 
which  causes  that  complete  loss  of  sexual  appetite 
sometimes  observed  in  married  women,  a  state  of  affairs 
prolific  of  conjugal  unhappiness. 

As  we  have  already  had  occasion  to  remark,  the 


—  39  — 
special  senses  frequently  become  anaesthetic  after 
severe  hysterical  attacks.  Sometimes  the  sense  of 
smell  and  taste  may  be  entirely  lost;  at  others  the 
sensory  impairment  is  unilateral.  Unilateral  and  even 
bilateral  deafness  are  sometimes  observed  in  the  ab- 
sence of  all  disturbances  affecting  the  peripheral  ap- 
paratus of  hearing. 

More  or  less  profound  visual  disturbances  are 
also  encountered  among  the  hysterical;  the  most  fre- 
quent of  these  is  probably  unilateral  amblyopia.  Com- 
plete amaurosis  is,  however,  also  observed.  Of 
ninety-three  cases  of  ansesthesia  of  different  sensory 
districts  examined  by  Briquet,*  amblyopia  was  present 
in  six  instances. 

Without  entering  upon  a  further  consideration  gf 
these  anomalies  of  vision,  which  have  been  exhaust- 
ively discussed  by  Charcot  and  others,  I  will  simply 
observe  that  examination  with  the  ophthalmoscop 
usually  fails  to  reveal  any  noteworthy  changes  in  the 
disks.  The  case  described  by  Galezowsky  exhibited 
infiltration  and  capillary  reddening  of  the  disk;  but 
the  amblyopia  had  existed  for  a  long  time  without 
opthalmoscopic  changes,  and  it  is  consequently  reason- 
able to  infer  that  the  latter  were  induced  by  some 
unknown  intercurrent  causes.  In  accordance  with 
what  we  already  know  of    the  amblitory  nature   of 


*  Quoted  by  Jolly,  op.  cit. 


—  40  — 

hysterical  symptoms,  we  are  not  surprised  that  both 
hysterical  blindness  and  deafness  sometimes  suddenly 
disappear  and  give  place  to  other  phenomena. 


CHAPTER  V. 

MOTOR  DISORDERS.— SPASMS.— PARALYSIS. 

Motor  Disorders. —  The  phenomena  of  motility, 
like  those  of  sensibility,  may  be  exaggerated  or 
diminished. 

Spasms. — These  may  be  of  a  tonic  or  clonic  na- 
ture, and  are  manifested  either  as  circumscribed 
twitchings  of  individual  muscles  or  groups  of  muscles, 
or  as  convulsions  involving  the  motor  apparatus,  more 
or  less  extensively. 

When  the  spasm  is  located  in  the  pharynx  and 
oesophagus,  it  gives  rise  to  the  sensation  of  choking 
known  as  globus  hystericus,  a  term  which  has  been  ap- 
plied to  this  condition  from  the  fact  that  the  subject 
complains  of  feeling  a  ball  in  her  throat.  So  con- 
vinced are  most  females  of  the  objective  reality  of 
these  sensations,  that  they  make  the  most  strenuous 
efforts  to  swallow  the  foreign  body,  apparently  lodged 
in  the  throat;  and,  failing  in  this,  they  attempt  to  dis- 
lodge it  with  the  finger,  or  by  the  aid  of  a  hair-pin. 
In  certain  cases  the  spasm  of  the  oesophagus  may  be 
so  severe  and  persistent  in  character  as  to  induce  the 
belief  that  organic  stricture  is  really  present.  When 
the  spasm  extends  to  the  tongue,  which  occasionally 
happens,  the  organ  is  distorted'  to  such  a  degree  as  to 
greatly  interfere  with  articulation  and  swallowing. 

Sometimes,  too,  the  stomach  becomes  involved  in 


—  4^  — 
the  spasm,  and,  consequently,  the  retention  of  food 
becomes  almost  impossible,  the  subject  vomiting  her 
food  immediately  after  it  had  been  swallowed.  Peris- 
taltic movements  of  various  portions  of  the  intestines, 
accompanied  by  borborygm,  eructations  and  colicky 
pains  are  sometimes  present.  When  this  spasm  of  the 
intestine  become  localized  and  persistent,  stricture 
may  be  produced.  As  a  result  of  this  condition  the 
progress  of  the  foeces  is  impeded,  while  at  the  same 
time,  owing  to  the  incarceration  of  gas  above  the  point 
of  constriction,  the  bowel  becomes  so  distended  as  to 
give  rise  to  the  phenomenon  known  as  a  "  phantom 
tumor."  Sometimes,  however  the  results  of  the  per- 
sistent spasm  are  even  more  serious,  and  a  veritable 
intestinal  obstruction  may  occur. 

The  genito-urinary  apparatus  may  also  become 
the  seat  of  spasm,  and  in  a  considerable  percentage  of 
cases  the  latter  gives  rise  to  spasmodic  retention  of 
urine,  which  is,  curiously  enough,  associated  with  a 
persistent  desire  to  urinate.  This  desire  to  micturate 
is  explicable  in  most  cases  by  an  unusually  hyperses- 
thetic  condition  of  the  bladder,  which  may  or  may  not 
be  associated  with  irritability  of  the  vagina  and  vulva. 

When  the  hyperaesthesia  of  the  genital  organs  is 
great,  reflex  activity  is  sometimes  increased  to  such  a 
degree  as  to  render  coitus  impossible.  Under  these 
circumstances  the  mere  contact  of  the  male  genital 
organs  with  the  vaginal  orifice  is  sufficient  to  provoke 
severe  and  painful  vaginismus.     Concerning  the  causa- 


—  43  — 
tion  of  vaginismus,  Scanzoni  published  some  interest- 
ing statistics  in  1868.  These  observations  have  been 
summarized  by  Dr.  T.  Gaillard  Thomas*  as  follows: 
"During  the  preceding  three  years  he  (Scanzoni)  had 
seen  thirty-four  marked  cases,  due  chiefly,  he  thought, 
to  violent  efforts  at  sexual  intercourse,  practiced  upon 
women  having  small  vaginas  and  well-developed 
hymens.  Scanzoni  found  that  twenty-five  of  his  thirty- 
four  patients  had  various  functional  and  organic  diffi- 
culties, which  in  twenty  cases  had  come  on  after 
marriage;  in  eleven  there  was  congestive  dysmenor- 
rhoea;  in  one,  amenorrhoea  had  existed  for  three  years; 
in  thirteen,  there  was  chronic  metritis;  four  had  either 
ante  or  retroversion;  in  one  there  was  perimetritis;  in 
seventeen,  chronic  uterme  catarrh;  in  fourteen,  vagi- 
nal catarrh;  in  one,  anteflexion;  in  two,  retroflexion; 
nine  had  urinal  difficulties;  one  had  inflammation  of 
the  right  Bartholin's  gland;  in  fourteen  there  were 
symptoms  of  anaemia;  and  in  seventeen  of  hysteria.'"  \ 

And  continuing.  Dr.  Thomas  \  proceeds  to  state 
that:  "Although  the  sexual  act  could  not  be  fully 
completed,  conception  was  not  entirely  impossible,  as 
out  of  the  thirty-four  cases  two  had  conceived;  in  the 
other  thirty-two,  sterile  marriages  had  existed  from  one 


*  A  Practical  Treatise  on  the  Diseases  of  Women,  by  T. 
Gaillard  Thomas,  M.  D.,  Philadelphia,  1878,  p.  143. 
f  The  italics  are  ours. 
X  Op.  et  loc.  cit. 


—  44  — 
to  eleven  years.  This  sterility  was  not  due  to  want  of 
sexual  desire,  but  arose  entirely  from  spasm  involving 
all  the  muscles  of  the  pelvis,  which  also  rendered  ex- 
amination, either  by  the  touch  or  speculum,  impossible 
without  the  use  of  an  anaesthetic." 

The  hysterical  attack,  which  we  shall  presently 
take  occasion  to  describe  more  in  detail,  is  frequently 
characterized  by  screaming,  crying  and  laughing  of  a 
more  or  less  spasmodic  nature.  In  this  connection  it 
is  well  to  bear  in  mind  that  the  spasmodic  closure  of 
the  glottis,  which  sometimes  takes  place  during  these 
seizures,  may  give  rise  to  dangerous  dyspnoea.  Con- 
sequently, the  medical  attendant  should  be  prepared 
to  act  with  energy  and  precision. 

Of  diagnostic  importance  only  secondary  to  globus 
are  the  more  or  less  incessant  facial  contortions,  the 
"facies  hysteria"  of  the  older  writers — an  appearance 
characterized  at  once  by  a  certain  fulness  of  the  cheeks 
and  a  drooping  of  the  eyelids. 

Paralysis. — Complete  or  partial  loss  of  muscular 
power  is  frequently  present  in  hysteria.  Sometimes 
the  paresis  is  exceedingly  limited  in  character,  involv- 
ing but  one  or  two  small  muscles.  Thus  it  is  probable 
that  the  drooping  of  the  eyelids,  so  characteristic  of 
hysterical  women,  is  due  to  weakness  of  the  lavator 
palpebrae  superiosis  muscles.  In  some  cases, however, 
the  paralysis  is  much  more  extensive,  involving  one  or 
more  limbs,  or  assuming  the  form  of  hemiplegia  or 
paraplegia. 


—  45  — 

The  evolution  of  these  motor  disturbances  is,  in 
some  cases,  extremely  gradual,  the  first  symptom 
worthy  of  note  being  a  sensation  of  weakness  or 
heaviness  in  the  affected  extremities.  Sometimes, 
however,  the  advent  of  the  paralysis  is  sudden,  and 
takes  place  without  the  slightest  warning,  usually  after 
an  hysterical  seizure. 

In  cases  of  hysterical  paraplegia,  in  which  the 
muscles  of  the  lower  extremities  are  only  partially  or 
slightly  affected,  the  patient  is  able  to  walk  about  by 
the  aid  of  a  cane  or  crutch;  when,  however,  the  motor 
disturbances  are  more  profound  in  character,  she  may 
be  confined  to  her  bed. 

With  the  more  or  less  extensive  paralysis  of  hys- 
teria, anaesthesia  is  frequently  associated.  Sometimes 
cutaneous  sensibility  is  alone  affected;  but,  on  the 
other  hand,  in  not  a  few  cases  the  anaesthesia  extends 
to  the  subjacent  muscles. 

Like  so  many  of  the  other  symptoms  of  hysteria, 
these  paralytic  phenomena  are  often  amblitory  and 
evanescent  in  character.  Sometimes  they  disappear 
from  one  side  of  the  body  only  to  reappear  on  the 
other.  Sometimes,  again,  the  paralysis  may  persist 
for  a  few  days,  weeks,  or  months,  and  then  suddenly 
disappear  altogether.  But  it  would  be  a  mistake  to 
infer  from  such  disappearance  that  the  subject  is 
henceforth  exempt  from  accidents  of  the  kind,  since  it 
not  infrequently  happens  that,  even  after  the  lapse  of 
several  years,  the  paralytic  symptoms  again  return 
subsequent  to  an  exceptionally  severe  seizure. 


-  46  — 

With  regard  to  the  differentiation  of  the  paralytic 
phenomena  of  hysteria  from  true  paralysis,  resulting 
from  organic  lesions,  this  much  may  be  briefly  stated: 
That  hysterical  paralysis  is,  almost  without  exception, 
accompanied  by  the  psychical  disturbances,  hyperaes- 
thesia,  spasms,  and  numerous  other  manifestations  of 
the  disease;  so  that  the  evidence  afforded  is  so  preg- 
nant that  mistakes  are  usually  easily  avoided. 

After  all  has  been  said,  however,  which  the  sub- 
ject admits  of,  it  must  be  admitted  that  where  the 
typical  hysterical  phenomena  are  slightly  pronounced 
errors  are  extremely  liable  to  occur.  But  to  admit 
this  fact  affords  no  extenuation  for  those  errors 
in  diagnosis  and  treatment  which  are  so  constantly 
perpetrated,  even  where  the  evidence  is  most  con- 
clusive. 

Before  concluding  the  consideration  of  the  motor 
anomalies  of  the  affection,  a  word  respecting  those 
contractures  which  have  been  so  repeatedly  and  ably 
described  by  recent  French  authors.* 

When  tonic  spasms  in  the  muscles  of  the  limbs 
are  both  severe  and  persistent,  certain  distortions  of 
the  latter  are  produced,  which  may  be  evanescent  or 
recurrent  in  character,  or  may  persist  for  a  series  of 
years.  If  the  contracture  be  situated  in  the  upper  ex- 
tremity,   the  forearm,    hand,  and   fingers  are    rigidly 


*  Vide  Charcot,  "  Lecons  sur  les  Maladies  du  System 
Nerveux,"  Paris,  1872-1873.  Also,  Bourneville  et  Voulet, 
"  De  la  Contracture  HyKterique,"  Paris,  1872. 


—  47    — 

flexed,  so  that  extension  is  often  impossible.  But  if 
the  spasmodic  condition  be  present  in  the  lower  limb 
the  latter  is  extended  upon  the  pelvis  and  the  leg  up- 
on the  thigh.  At  the  same  time  the  foot  usually  as- 
sumes the  attitude  of  talipes  equino-varus,  while, 
owing  to  spasm  of  the  adductors,  the  thighs  are  rigidly 
approximated. 

Sometimes  these  contractures  may  persist  for  a 
series  of  years  and  then  disappear  without  other  warn- 
ing than  some  form  of  violent  mental  disturbance. 
The  final  result  is  not,  however,  always  so  fortunate; 
since,  after  the  contracture  has  continued  for  a  long 
time,  atrophy  of  the  affected  muscles  may  occur.  If, 
under  these  circumstances,  a  careful  electrical  exam- 
imation  be  instituted,  it  is  often  possible  to  demon- 
strate a  well-marked  degenerative  reaction. 

Tremor  is  sometimes  observed  to  accompany 
these  contractures,  and  may  be  evoked  by  any  sudden 
tension  of  the  muscular  system.  In  exquisite  cases 
the  knee-tendon  reflexes  may  be  exaggerated.  In  a 
case  of  this  kind,  in  which  the  contractures  had  per- 
sisted for  many  years,  Charcot*  was  able  to  demon- 
strate, by  post  mortem  examination,  sclerosis  of  both 
lateral  columns  of  'he  cord.  To  infer,  however,  from 
this  fact  that  the  presence  of  tremor  in  these  cases  is 
an  infallible  indication  of  an  organic  lesion  of  the 
lateral  columns  is  manifestly  impossible,  since  recovery 


*  Cited  by  Bourneville,  op.  cit. 


sometimes  takes  place  after  the  tremulous  condition 
has  persisted  for  a  long  time.  On  the  other  hand  it 
is  possible,  and  perhaps  even  propable,  that  in  old 
contractures  with  atrophy  a  lesion  more  or  less  per- 
manent in  character  is  actually  present;  and,  further- 
more, it  is  even  conceivable  that  such  a  lesion  might 
extend  to  the  anterior  horns  of  gray  matter.  Assum- 
ing this  to  be  the  actual  state  of  things,  both  the  per- 
manent contracture  and  subsequent  atrophy  are  easily 
accounted  for.  Speculations  on  this  point  are,  how- 
ever, of  little  avail  in  the  present  state  of  knowledge; 
and,  in  spite  of  the  mterest  attaching  to  Charcot's 
case,  a  single  instance  of  this  kind  cannot  set  at  rest  a 
question  of  such  magnitude.  Evidence  in  corrobora- 
tion or  rebuttal  is,  therefore,  in  order. 

It  should  be  borne  in  mind,  in  this  connection, 
that  tremor  is  not,  however,  necessarily  always  accom- 
panied by  contracture,  but  may  exist  quite  independ- 
ently of  the  latter.  I  have  at  present  a  case  of  this 
kind  under  treatment.  The  patient,  a  young  man  of 
thirty,  exhibits  a  variety  of  hysterical  mental  and 
physical  symptoms,  and  not  the  least  interesting  feature 
in  the  case  is  persistent  tremor  of  the  facial  muscles, 
which  is  also  present  to  some  extent  in  the  hands. 
There  is,  however,  no  tremor  in  the  tongue.  The 
tremulous  condition,  which  I  have  already  succeeded 
in  ameliorating  to  a  considerable  extent,  is  excited  by 
insignificent  emotional  disturbances,  and  resembles 
closely  the  tremor  of  paralysis  agitans. 


CHAPTER  VI. 

VASO-MOTOR    DISORDERS— THE   HYSTERICAL 
COUGH. 

Vaso-motor  Disorders. — These  are  frequently  ob- 
served in  hysteria,  and  may  consist  in  a  local  diminu- 
tion in  temperature — a  condtion  peculiarly  prone  to 
occur  in  hysterical  joint  trouble,  as  Brodie  and  others 
have  observed;  or  the  vaso-motor  insufficiency  is  ex- 
hibited in  frequent  and  unaccountable  blushing.  Car- 
diac derangements  of  a  functional  nature  are  also 
frequent  accompaniments  of  hysteria,  and  are  usually 
associated  with  general  anaemia. 

The  various  miraculous  accounts  of  hysterical 
persons,  whose  wounds  "emitted  little  or  no  blood," 
are  probably  founded  upon  the  observation  that  bleed- 
ing is  much  less  profuse  in  the  anaesthetic  regions  of 
such  individuals  than  in  other  portions  of  the  body. 
Charcot,  I  believe,  was  the  first  to  draw  attention  to 
this  fact. 

Remarkable  and  sudden  elevations  of  tempera- 
ture are  sometimes  observed  in  hysteria.  These  ther- 
mic variations  have  been  recorded  in  medical  literature 
by  a  number  of  reliable  witnesses;  so  that,  although 
intentional  deception  has  undoubtedly  been  resorted 
to  in  some  instances,  it  must  be  regarded  rather  as  the 
exception  than  the  rule.  Some  of  these  cases  possess 
great  interest  from  a  theoretic  point  of  view. 


—  5°  — 

The  Hyste7-ical  Cough. — Among  the  local  manifes- 
tations of  hysteria,  to  which  more  or  less  extended 
reference  has  already  been  made,  there  remains  to  be 
enumerated  the  phenomenon  known  as  the  hysterical 
cough.  It  consists  in  a  succession  of  explosions  of 
air  through  the  glottis,  of  such  rapidity  as  to  cause 
the  impression  that  the  cough  is  continuous.  These 
paroxysms  of  coughing  are  rhythmical  in  character, 
and  at  the  same  time  wholly  unaccompanied  by  ex- 
pectoration. There  is  no  dyspnoea  during  the  interval; 
respiration  is  somewhat  less  profound  than  usual,  and 
physical  examination  of  the  chest  yields  only  negative 
results. 

As  a  rule  the  character  of  the  cough  is  hard  and 
dry;  but  in  its  more  complex  manifestations  it  is  some- 
times accompanied  by  aphony  and  vomiting. 

The  hysterical  cough  is  a  chronic  affection,  re- 
markable for  its  tenacity,  persisting  for  months  and 
even  for  years.  It  is,  moreov.er,  more  or  less  exempt 
according  to  Lasegue,  from  the  influences  arising  from 
menstruation  and  other  intercurrent  events  of  physio- 
logical consequence.  The  results  of  treatment  are, 
as  a  rule,  by  no  means  flattering,  and  recovery  usu- 
ally takes  place  suddenly  and  without  warning,  or  by 
slow  and  almost  imperceptible  degrees.  In  whatever 
manner  recovery  takes  place  there  can  be  no  cer- 
tainty that  the  restoration  to  health  is  permanent, 
since  relapses  are  of  frequent  occurrence. 

The  affection  is  confined  to  women,  and  has  al- 


—  51  — 

most  always  been  observed  before  the  age  of  five 
and  twenty.* 

According  to  Lasegue  it  is  peculiar  to  no  par- 
ticular form  of  hysteria,  though  Sydenham  is  of  a  con- 
trary opinion,  f 

When  the  origin  of  the  attack  is  traceable  to  a 
simple  cold,  the  subjects  usually  exhibit  no  particular 
predisposition  to  catarrhal  or  pulmonary  affections. 
Upon  close  inquirj^,  however,  most  cases  of  the  kind 
disclose  the  histories  of  previous  hysterical  attacks, 
or  at  all  events  there  is  evidence  of  strong  neurotic 
tendencies. 

During  the  persistence  of  the  cough  the  appetite 
is  diminished  and  the  digestive  functions  may  suffer 
more  or  less.  There  may  also  be  a  considerable  loss 
of  flesh.  But  whatever  the  general  symptoms  ob- 
served, the  latter  are  rarely  of  sufficient  gravity  to 
justify  the  anticipation  of  a  fatal  termination.  With- 
out entering  upon  the  details  of  the  subject  further, 
I  will  cite  a  case  or  two  from  my  own  practice  and 
that  of  others.  The  following  extraordinary  case  of 
hysterical  cough  is  reported  by  Dr.  Hartley:|     "  In 


*  "  De  la  Toux  Hysterique,"  by  Dr.  Ch.  Lasegue, 
Archives  Generales  de  Medicine,  1854,  vol.  I,  p.  513. 

f  Op.  cit.,  p.  517. 

X  Extraordinary  case  of  spasmodic  cough  in  a  girl  aged 
fourteen  years.  Recovery  under  the  influence  of  valerianate  of 
zinc  and  the  cold  douche.  The  Medical  Times  and  Gazette, 
vol.  II.,  p.  116. 


—  52  — 

the  end  of  January  last  Rebecca  D.,  a  tolerably  well- 
developed,  dark-complexioned  girl  of  fourteen  years 
of  age,  came  under  the  care  of  Dr.  Hartle)'-,  at  Uni- 
versity College  Hospital,  complaining  of  weakness, 
loss  of  appetite,  and  suppression  of  the  menses.  She 
had  menstruated  regularly  two  or  three  times,  and 
then  ceased  to  do  so  during  the  three  months  prior  to 
her  appearance  at  the  hospital.  Tonics,  both  mineral 
and  vegetable,  were  administered,  and  the  girl  went 
on  improving  until  March  31,  when  the  mother 
brought  her  back  to  the  hospital,  saying  that  four- 
teen days  previously  she  had  been  seized  with  a 
cough,  which  gradually  got  worse,  until  it  became  al- 
most incessant.  In  fact,  according  to  the  mother's 
account,  the  girl  never  ceased  coughing  from  the 
time  she  rose  in  the  morning  till  the  time  she  went  to 
bed  at  night.  While  standing  in  the  waiting  room  the 
patient  coughed  incessantly,  and  as  she  was  a  highly 
hysterical  girl  she  was  kept  there  for  nearly  an  hour, 
in  order  to  try  and  tire  her  out.  But  at  the  end  of 
the  hour  she  was  just  as  bad  as  when  she  entered 
the  room.  It  was  one  continual  round  of  short  barks 
(she  did  not  give  herself  time  to  fill  the  lungs  com- 
pletely in  order  to  be  able  to  give  a  proper  cough), 
with  no  perceptible  interval  even  for  respiratory  pur- 
poses. The  mother  declared  that  she  could  not  take 
food.  On  being  scolded  and  ordered  to  cease  cough- 
ing, she  burst  into  tears;  but  the  cough  went  on. 
The  patient  answered  questions  hurriedly,  and  while 


doing  50  she  did  not  cough,  but  with  the  last  words 
the  cough  recommenced.  After  a  time  it  was  found 
that  she  could  control  the  cough  by  an  effort  of  the 
will,  but  only  for  a  few  seconds.  There  was  no 
chest  affection,  and  no  apparent  disease  of  the  throat 
or  fauces.  The  cough  seemed  to  be  entirely  spas- 
modic-Iaryngeal  and  the  result  of  hysteria.  One  of 
the  students  counted  at  inter^-als  the  frequency  of 
the  cough,  and  without  the  patient's  knowledge,  and 
it  was  found  that  she  coughed  at  the  regular  rate 
of  seventy  per  minute,  or  four  thousand  two  hund- 
red times  per  hour.  And  reckoning  that  the  girl 
coughed  during  twelve  hours  out  of  the  twenty-four, 
if  the  mother,  an  intelligent  and  not  at  all  enthu- 
siastic female,  was  to  be  believed,  the  girl  coughed 
more  than  that— she  must  have  coughed  the  enor- 
mous number  of  fifty  thousand  four  hundred  times 
daily (5 0,400).  A  mixture  containing  the  valerianate 
of  zinc,  the  tincture  of  asafoetida,  and  camphor  was 
ordered  to  be  taken  three  times  a  day,  and  a  cold 
douche  with  frictions  to  the  spine  to  be  applied  night 
and  morning.  On  April  7  the  patient  was  again 
brought  to  Dr.  Hartley,  and  the  mother  with  evident 
satisfaction  stated  that  the  cough  had  gradually 
ceased  three  days  after  the  commencement  of  the 
treatment,  and  now  the  patient  only  coughed  once  or 
twice  a  dav.  On  questioning  the  mother  closely  she 
stated  positively  that  the  girl  had  coughed  incessantly, 
except  when  she  was  in  bed  (it  ceased  immediately  on 


—   54  — 

lying  down),  during  eight  days,  and  that  the  cough 
was  just  as  frequent  at  home  as  it  was  while  the 
patient  was  in  the  hospital.  So  that  if  we  even 
reckon  seventy  per  minute,  and  for  only  nine  hours  a 
day,  during  the  eight  days  she  would  still  have  cough- 
ed the  almost  fabulous  number  of  302,400  times.  As 
the  treatment  related  had  proved  so  successful,  it  was 
continued  for  a  fortnight,  and  then  changed  to  quassia 
and  iron. 

The  catamenia  reappeared  on  May  19,  and  from 
that  time  the  girl  went  on  improving  until  June  2, 
when  she  was  dismissed  as  cured. 

The  following  case  came  under  my  observation 
some  years  since,  while  serving  a  portion  of  my 
medical  apprenticeship  as  resident  physician  to  the 
Hudson  River  State  Hospital  for  the  Insane: 

A.  C,  a  girl  aged  nineteen  years,  of  nervous  tem- 
perament, was  committed  to  the  hospital  on  account 
of  several  mild  attacks  of  what  was  evidently  subacute 
maniacal  excitement.  The  cause  of  the  last  attack 
was  a  severe  fright  caused  by  threats,  on  the  part  of 
her  mother,  of  sending  her  to  jail  if  she  did  not  "stop 
her  everlasting  coughing." 

Upon  entrance  into  the  hospital,  and  while  I  was 
endeavoring  to  record  the  principal  points  in  her  case, 
she  coughed  so  incessantly  and  loudly  that  I  was 
obliged  to  have  her  conducted  to  a  remote  female 
ward.  On  the  following  day,  I  learned,  upon  inquiry, 
from   the   attendant   that   she    was   menstruating  co- 


—  55  — 
piously,  and  that  she  was  suffering  acutely  from  dys- 
menorrhoea.  Her  conduct  was  mischievous  in  the  ex- 
treme; she  called  out  the  window  to  the  patients  en- 
gaged in  work  upon  the  farm,  and  addressed  them  as 
angels;  she  tore  the  aprons  and  other  articles  of  ap- 
parel from  the  persons  of  the  female  patients  about 
her,  and  then  ran  away  laughing  and  crying  in  a  most 
hysterical  manner.  After  every  explosion  of  this  kind 
she  was  seized  with  violent  and  continuous  coughing, 
which  lasted  for  two  or  three  hours. 

After  she  had  remained  in  the  hospital  for  some 
months,  it  was  found  that  these  attacks  of  coughing 
invariably  began  a  short  time  before  menstruation  and 
continued  until  a  day  or  two  after  the  subsidence  of 
the  same.* 

Examination  of  the  chest  and  larynx  yielded  ab- 
solutely negative  results. 

What  eventually  became  of  this  patient  I  am  un- 
able to  state.  She  was  removed  from  the  hospital  up- 
on the  subsidence  of  the  mental  symptoms;  but  the  at- 
tacks of  coughing  remained  unaffected  up  to  the  time 
of  her  departure. 

The  attacks  ceased  completely  during  sleep  in 
this  case,  a  point  upon  which  great  stress  is  placed  by 
some  diagnosticians. 


*The  connection  between  the  menses  and  the  cough  is 
apparently  contrary  to  the  experiences  of  Lasegue  and  others; 
though  I  am  convinced  from  this  case  of  its  existence,  at  least 
in  some  cases. 


_  56  - 

Dr.  Synclair*  presents  the  following  case  as  an 
instance  of  the  "  acute  "  forms  of  hysterical  cough: 

A  young  girl  of  eighteen  years,  having  had  sev- 
eral attacks  of  hysteria,  complained  of  rheumatic  pains 
and  headache  without  febrile  disturbances.  Fifty 
drops  of  laudanum  mixed  with  a  little  water  were 
prescribed  for  her.  On  the  2 2d  of  October,  immedi- 
ately after  the  administration  of  the  medicine,  the  pa- 
tient was  seized  with  a  continuous  cough.  There  was 
no  dyspnoea,  no  febrile  movement  and  no  pain  about 
the  throat.  At  night,  while  asleep,  the  cough  ceased 
altogether,  but  only  to  return  the  following  morning 
upon  awaking.  Thus  matters  continued  in  spite  of 
treatment  until  the  fourth  day,  when  the  cough  sud- 
denly disappeared  to  return  no  more. 

This  case  does  not  appear  sufficient  to  establish 
the  existence  of  an  acute  variety  of  the  affection,  and 
I  therefore  cite  it  merely  on  account  of  the  intrmsic 
interest  which  attaches  to  the  case,  and  entirely  irre- 
spective of  any  theoretic  significance  which  it  may 
possibly  possess. 


*  Edinburg  Medical  and  Surgical  Journal,  1825. 


CHAPTER  VII. 

THE  HYSTERICAL   PAROXYSM. 

The  Hysterical  Paroxsym. — By  hysterical  attacks 
are  commonly  understood  certain  general  tonic  and 
clonic  convulsions  associated  with  peculiar  psychical 
manifestations. 

It  is  impossible  to  give  a  description  of  these  at- 
tacks of  sufficient  breadth  to  cover  the  manifold  varia- 
tions of  which  they  are  capable,  and  we  shall  therefore 
confine  ourselves  to  a  delineation  of  the  more  salient 
features,  trusting  to  the  resources  of  individual  ex- 
perience to  fill  in  the  details  of  the  picture. 

In  the  milder  forms  of  the  attack  there  are 
rhythmical  clonic  spasms  of  the  extremities,  while  at 
the  same  time  respiration  is  accelerated,  irregular,  or 
interrupted.  Consciousness,  however,  is  not  abolished, 
since  the  subject  gives  evidence  of  understanding 
what  is  said  in  her  immediate  neighborhood,  and  is 
also  able  to  exercise  a  certain  amount  of  control  over 
her  movements.  The  duration  of  an  attack  of  this 
kind  is  usually  brief,  rarely  lasting  more  than  a  few 
minutes.  Sometimes,  however,  the  primary  attack  is 
followed  by  a  rapidly  occurring  series  of  others,  and 
we  have  a  somewhat  analogous  condition  to  that 
which  is  present  in  certain  forms  of  epilepsy.  The 
course  of  the  attack  is,  however,  by  no  means   always 


—  5»  — 

so  benignant  in  character  as  the  foregoing  description 
would  indicate.  In  the  more  severe  forms  of  the 
seizure,  consciousness  is  completely  lost;  the  convul- 
sions become  tetanic,  the  trunk  and  extremities  be- 
come fixed  and  variously  distorted;  there  is  frothing 
at  the  mouth  and  the  respiration  becomes  slow  and 
stertorous.  The  convulsions,  which  were  alternately 
tonic  and  clonic  in  character,  resemble  so  closely  those 
of  true  epilepsy  that  the  seizure  cannot  be  dis- 
tinguished from  the  latter.  This  close  resemblance 
has  gained  for  these  paroxysms  the  designation  of 
^''  Hystero- Epilepsy,''  a  title  which  has  found  favor 
among  recent  medical  writers  of  France  where  a  vast 
literature  upon  the  subject  has  made  its  appearance. 

Previous  to  the  attack,  and  indeed  throughout 
the  interparoxysmal  period,  the  hystero-epileptic  sub- 
jects complain  of  the  most  varied  hysterical  symptoms. 
Hemiangesthesia  and  hyperaesthesia  of  the  ovaries 
are  among  the  most  constant  symptoms  observed. 

The  paroxysm  itself  is  usually  preceded  by  an 
aura  emanating  from  the  affected  ovary  and  proceed- 
ing in  an  upward  direction.  When  the  aura  has  at- 
tained the  upper  portion  of  the  trunk,  the  subject  utters 
the  loud  and  piercing  cry  peculiar  to  epileptics,  and 
falls  to  the  ground  in  an  insensible  condition.  Tetani- 
form  spasms  of  the  muscles  now  makes  their  appear- 
ance. The  muscles  of  the  neck,  trunk,  upper  and 
lower  extremities,  are  rigid;  respiration  is  labored  and 
infrequent;  the  mouth  is  bedecked  with  foam,  and  the 


—  59  — 
tongue  is  protruded  between  the  teeth,  lending  a  re- 
pulsive appearance  to  the  countenance. 

Upon  the  stage  of  tetanic  muscular  contraction, 
there  succeeds  a  period  of  complete  muscular  relaxa- 
tion, during  the  continuance  of  which  the  breathing 
is  stertorous  and  the  mental  condition  one  of  coma. 
Soon,  however,  the  exaggerated  muscular  phenomena 
again  make  their  appearance,  this  time  in  the  form  of 
violent  interrupted  contractions,  which  give  rise  to  the 
most  varied  distortions.  The  body  is  bent  violently 
backwards  and  maintained  in  an  opisthotonotic 
position;  or  it  may  be  rigidly  extended,  while  the 
limbs  are  flexed  or  extended,  or  it  may  be  bent  for- 
wards or  laterally  (pleurosthotonos).  Sometimes  the 
subject  executes  gesticulations  of  an  evident  purposive 
nature,  which,  though  in  some  cases  characterized  by 
violence,  are  quite  as  often  devoid  of  all  injurious  in- 
tent, and  recall  forcibly  the  antics  of  a  harlequin.  At 
such  times  the  patient  endeavors  to  stand  upon  her 
head,  turns  somersaults,  or  bows  with  mock  gravity  to 
those  about  her. 

By  degrees  the  purposive  character  of  these  ges- 
tures become  more  pronounced,  and  at  the  same  time 
the  emotional  element  enters  more  and  more  into  their 
composition.  In  the  beginning  of  this  stage  of  the 
attack,^  the  patient,  as  a  rule,  assumes  attitudes  of  a 
threatening  character.  The  brows  are  contracted; 
the  lips  are  compressed  and  the  whole  facial  expres- 
sion is  one  of  rage   and   resentment.     Sometimes  the 


—  6o  — 

subject  suddenly  starts  from  a  recumbent  posture,  and 
clenches  her  fists,  at  the  same  time  fixing  a  look  of 
defiance  upon  some  unseen  enemy.  After  the  lapse 
of  a  few  moments,  however,  the  attitude  of  anger  is 
succeeded  by  one  of  profound  apprehension,  which  is 
of  short  duration  and  is  in  turn  followed  by  an  ex- 
pression of  countenance  indicative  of  the  most  beatific 
hallucinations.  The  expression  of  beatitude  gradually 
passess  into  one  indicative  of  extreme  voluptuousness, 
and  is  accompanied  or  succeeded  by  movements  of  a 
correspondingly  lascivious  nature.  This  stage  is  fol- 
lowed by  a  mental  condition  resembling  somewhat 
that  of  delirium  tremens.  She  sees  frogs,  mice,  ser- 
pents, rats,  and  other  offensive  creatures  which  causes 
her  to  cry  out  with  apprehension,  while  at  the  same 
time  her  countenance  presents  a  frightful  picture  of 
mingled  fear  and  disgust. 

By  degrees  the  terrible  hallucinations  which  lie 
at  the  root  of  these  phenomena  subside;  the  face  of 
the  subject  wears  an  expression  of  contrition,  and  with 
clasped  hands  she  begs  for  clemency.  From  this 
period  recovery  is  rapid.  The  subject  has  alternate 
fits  of  weeping  and  hysterical  loquacity,  during  which 
she  upbraids  those  about  her  for  being  the  cause  of 
all  her  distress. 

It  is  very  easy  to  provoke  an  attack  resembling 
that  above  described,  in  a  person  afflicted  with  hystero- 
epilepsy.  Thus,  the  sudden  pinching  of  the  skin  in 
the  neighborhood  of  the  inguinal  region  and  about 
the  breasts  is  sufficient  to  cause  a  seizure. 


—  6i   — 

Attacks  of  hystero-epilepsy  are  much  less  frequent 
in  this  country  than  abroad,  and  when  they  do  occur, 
the  phenomena  presented  are  usually  greatly  modified. 
Of  the  causation  and  pathology  of  hystero-epilepsy 
little  of  a  specific  nature  can  be  added;  the  most  that 
we  can  do  so  far  as  active  interference  is  concerned, 
is  to  utilize  what  is  known  concerning  the  mechanism 
of  the  epileptic  seizure,  and  to  make  due  allowance 
for  the  hysterical  elements  of  the  picture. 


CHAPTER  VIII. 

HYSTERIA    IN     CHILDREN— HYSTERIA    IN    MEN. 

Hysteria  in  Children. — As  we  have  already  had 
occasion  to  observe,  when  considering  the  etiology  of 
the  affection,  hysteria  may  occur  in  girls  and  boys 
under  ten  years  of  age;  but  the  disease  is  far  more 
frequent  about  the  time  of  puberty.  In  very  young 
girls  the  appearance  of  the  disease  is  characterized  by 
alternate  laughter  and  weeping,  as  well  as  extreme 
mental  irritability  and  intellectual  inertia.  The  symp- 
toms manifested  by  many  boys  at  the  time  of  puberty 
are  analogous  in  their  general  characteristics.  Besides 
the  mental  phenomena,  however,  the  young  boys  thus 
affected  execute  the  most  extraordinary  gestures  and 
gymnastics.  They  stand  upon  their  heads,  creep 
about  the  floor,  uttering  cries  in  imitation  of  various 
animals,  and  otherwise  misdemean  themselves.  Mas- 
turbation is  also  common  in  both  sexes  at  this  time. 
The  following  cases  reported  by  Dr.  William  Roberts* 
are  good  illustrations  of  hysteria  in  boys: 


*"  Cases  of  Hysteria  in  Boys,"  by  William  Roberts, 
M.  D.  A  paper  read  before  the  Manchester  Medical  Society, 
"The  Practitioner,"  1879,  vol.  xxiii,  p.  339,  et  seq.  Vide:  also 
"Cases  of  Malingering,"  communicated  by  Mr.  H.  T.  Batlin, 
Registrar  of  the  Hospital  for  Sick  Children,  London,  1871. 
"On  Hysteria  in  Children,"  by  Dr.  H.  Paris,  Journal  de 
Therapeutique,  May  lo,  1880;  also  London  Medical  Record,  viii, 
p.  232. 


_  63  - 

Case  I. — "The  first  example  of  hysteria  in  boys 
that  arrested  my  attention  was  the  son  of  a  merchant 
in  this  town,  whom  I  saw  in  1870,  This  boy  at  the 
age  of  thirteen,  and  as  a  sequence  to  some  trifling  ail- 
ment, began  to  show  hypochondriacal  symptoms.  He 
became  depressed  in  spirits,  and  dyspeptic,  and  suf- 
fered from  various  undefinable  ailments.  Eight 
months  later  a  dry  cough  set  in,  which  soon  assumed 
the  character  of  the  true  hysterical  bark.  I  was  con- 
sulted some  four  months  after  this  began.  The  bark 
had  now  degenerated  into  a  hoarse  sound,  resembling 
the  bleating  of  a  goat.  The  boy  persisted  for  many 
months  in  uttering  this  horrible  noise  oil  day  long, 
almost  without  cessation,  except  during  the  hours  of 
sleep.  At  one  time,  for  about  four  months,  the  symp- . 
toms  exhibited  a  curious  diurnal  periodicity.  As  soon 
as  the  boy  awoke  in  the  morning  he  began  to  bleat 
every  two  or  three  minutes,  and  continue  to  do  so  for 
about  three  hours,  and  then  cease;  but  precisely  at 
eight  o'clock  in  the  evening,  with  the  regularity  of 
clock  work,  he  began  to  bleat  again,  and  continued  to 
do  so  until  he  went  to  bed  and  fell  asleep.  These 
symptoms  went  on  altogether  for  about  fifteen  months, 
and  then  gradually  subsided.  Since  then  this  boy  has 
grown  into  a  fine,  strong  young  man.  There  could 
be  no  doubt  as  to  the  hysterical  nature  of  the  symp- 
toms in  this  case.  The  patient  was  seen  by  Gendrin, 
of  Paris,  and  by  Sir  William  Gull,  both  of  whom  pro- 
nounced  the  case  to  be  one   of  pure   hysteria.     An 


—  64  — 

interesting  episode  occurred  during  the  progress  of 
the  case.  The  boy  was  separated  a  good  deal  from 
his  brothers  and  sisters  during  the  continuance  of  his 
ailment,  but  on  one  occasion  he  passed  some  days  in 
the  society  of  his  elder  brother.  Some  four  months 
afterwards  this  brother  had  an  attack  of  hysterical 
barking,  which  lasted  a  fortnight  and  then  passed  off. 
A  sister  also  was  subsequently  seized  with  similar 
symptoms.  She  was  nine  years  of  age  when  her 
second  brother — the  subject  of  this  history — was  suf- 
fering from  the  above-described  bleating.  When  she 
reached  the  age  of  fifteen,  four  years  after  her  broth- 
er's recovery,  she  began  to  "bark"  and  show  other 
signs  of  hysteria.  In  her  case  the  bark  became  a  sort 
of  hoarse  growl,  which  continued  almost  without  inter- 
ruption for  nearly  three  years,  and  then  slowly  passed 
away.  In  this  family  the  hysterical  bias  was  distinctly 
inherited  from  the  mother,  who,  in  her  youth,  dis- 
played severe  hysterical  symptoms  of  the  classical 
type."  The  subjoined  case  quoted  from  the  same 
authority  is  an  illustration  of  the  fact  that  hysteria  is 
sometimes  developed  during  ths  period  of  feebleness 
which  is  associated  with  convalescence  from  an  acute 
disorder. 

Case  II. — ''  The  subject  was  a  boy  between  eight 
and  nine  years  of  age,  whom  I  visited  last  year  with 
Dr.  Mules,  of  Bowdoin.  He  was  the  second  child  of 
a  family  of  six.  Dr.  Mules  informed  me  that  three 
weeks  previous  the  boy  was  commencing  to  be  conva- 


-  65  - 

lescent  from  a  febrile  attack  of  doubtful  character, 
when  he  was  suddenly  seized  with  paroxysms  of  loud, 
passionate,  tearless  crying,  with  incoherent  ravings  of 
a  most  alarming  and  distressing  character.  The  par- 
oxysms continued  for  a  week  almost  without  interrup- 
tion. At  the  end  of  this  week  they  suddenly  ceased, 
and  the  boy  appeared  almost  quite  well  again.  In  a 
few  days,  however,  they  recommenced,  but  not  so 
continuously.  The  paroxysms  now  lasted  two  or  three 
hours,  and  recurred  three  or  four  times  a  day.  In  the 
intervals  between  them  the  boy  appeared  quite  well, 
eating  and  sleeping  and  amusing  himself  like  a  boy  in 
health.  When  I  saw  the  patient  he  was  in  his  bed- 
room, looking  calm  and  collected,  with  a  soft,  smiling 
demeanor.  Soon  after  we  had  descended  into  the  sit- 
tingroom  to  hold  our  consultation  one  of  the  parox- 
ysms broke  forth,  and  we  heard  the  boy  screaming. 
We  went  up-stairs  into  his  bed-room  and  found  the 
boy  passionately  crying  and  clinging  to  his  mother,  as 
if  in  the  extremity  of  terror.  Nothing  could  pacify 
him,  and  when  we  left  the  house  the  paroxysm  was 
still  proceeding.  To  my  mind  the  attack  had  an  un- 
equivocally hysterical  complexion.  What  else  could 
it  be  ?  The  symptoms  evidently  concerned,  and  con- 
cerned alone,  the  nervous  system;  and  they  resembled 
those  of  no  disease  in  the  nosological  category  except 
those  of  the  chameleon  of  patholog}^,  hysteria.  As 
these  paroxysms  had  now  persisted  without  ameliora- 
tion for  a  period  of  three  weeks,  in  spite  of  the  resto- 

6  z 


—  ae- 
ration of  the  general  health,  we  decided  to  send  the 
child  away  from  home,  in  order  to  eliminate  that  most 
fruitful  of  all  promotors  of  hysterical  manifestations, 
home  surroundings  and  sympathy.  The  interrupted 
galvanic  current  was  also  directed  to  be  applied  daily. 
Under  this  treatment  the  attacks  became  less  and  less 
frequent,  and  finally,  in  about  six  weeks,  ceased  alto- 
gether; and  the  boy  has  since  remained  in  perfect 
health.  I  must  allow  that  the  diagnosis  in  this  case 
was  not  so  plain  and  undoubted  as  in  the  preceding, 
but  if  any  one  doubts  its  correctness,  I  would  ask  him 
this  question:  Suppose  he  saw  these  symptoms  in  a 
young  girl  on  the  threshold  of  puberty,  what  would  he 
call  the  disorder?" 

In  the  subsequent  course  of  his  paper.  Dr. 
Roberts  reports  cases  which  he  considers  to  be  in- 
stances of  hysterical  contracture  and  "  a  clumsy  imita- 
tion of  epilepsy."  The  ages  of  the  subjects  were  eight 
and  eleven  years  respectively. 

While  I  am  not  prepared  to  question  the  diag- 
nosis in  these  last  cases,  I  cannot  help  believing  that 
such  instances  must  be  comparatively  rare,  much  less 
frequent  in  fact  than  the  variety  of  the  affection  ex- 
emplified in  the  first  two  cases.  Of  that  form  of  the 
affection,  which  is  characterized  by  uncouth  noises, 
alternate  lachrymation,  and  spasmodic  laughter,  I 
have  seen  several  instances,  as  well  as  of  that  variety 
of  the  disease  in  which  the  boys  run  about  upon  their 
hands    and    knees,    uttering    barks    and    discordant 


-  67  - 

howls,  or  upsetting  chairs  and  other  articles  of  furni- 
ture. 

Hysteria  inMenJ^' — It  was  formerly  supposed  that 
hysteria  was  entirely  confined  to  the  female  sex;  but, 
as  we  have  already  had  occasion  to  remark,  in  the 
course  of  this  discussion,  recent  writers  admit  that  the 
affection  is  encountered  in  the  male  sex,  though  far 
less  frequently  than  among  women.  In  many  of  the 
so-called  cases  of  hysteria,  however,  symptoms  of 
cerebral  exhaustion  are  a  far  more  prominent  feature 
than  the  purely  hysterical  manifestations;  so  that  to 
classify  such  cases  as  bona  fide  instances  of  hysteria 
would  be  a  manifest  error.  In  all  instances  where 
there  is  doubt  as  to  whether  we  have  to  do  with  a  case 
of  hypochondriasis,  cerebral  exhaustion,  or  cerebral 
irritability,  the  best  we  can  do  is  to  classify  the  affec- 
tion according  to  the  characteristics  of  its  most  pre- 
dominant symptoms.  This  is  an  axiom  which,  though 
it  fails  perhaps  to  fulfill  the  most  ideal  theoretic  exi- 
gencies of  the  problem,  will  be  found  eminently  useful 
in  practice.  I  have  laid  particular  stress  upon  this 
point  in  the  classification  of  obscure  functional  affec- 
tions of  the  nervous  system  in  former  publications.! 


*  See  "  A  Case  of  Aggravated  Hysteria  occurring  in  a 
Man,"  under  the  care  of  Dr.  Todd.  Recovery.  The  Medical 
Times  and  Gazette,  New  Series,  vol.  vii.,  p.  242. 

f  "  On  the  Nature  of  Nervousness,"  by  J.  Leonard  Corn- 
ing. The  Medical  Gazette,  New  York,  Nov.  24,  1883.  Also 
"  A  Treatise  on  Brain  Exhaustion,"  by  J.  Leonard  Corning, 
D.  Appleton  &  Co.,  1884,  p.  116,  et  seq. 


CHAPTER  IX. 

CAUSATION.— PATHOLOGY.— DIAGNOSIS. 

Causation. — Hereditary  influence  constitutes  an 
important  factor  in  the  etiology  of  hysteria.  The 
affection  is,  moreover,  far  more  common  among 
females  than  among  males.  This  preponderance  of 
the  disease  among  women  is  owing,  in  great  measure, 
to  the  increased  development  of  the  em^otional  system 
in  the  latter — a  state  of  things  which  is  greatly 
fostered  by  the  sensational  nature  of  many  features  of 
modern  social  life.  But  while  sensational  literature, 
exaggerated  drama,  and  the  innumerable  other  ex- 
travagancies of  society  undoubtedly  play  a  prominent 
part  it  the  causation  of  the  disease,  it  is  equally  cer- 
certain  that  morbid  states  of  the  sexual  apparatus  are 
not  without  etiological  influence.  Proof  of  the  truth 
of  this  proposition  is  seen  in  the  extraordinary  ex- 
acerbation of  symptoms,  which  takes  place  in  hysterical 
women  at  the  period  of  menstruation,  and  in  the  fact 
that  the  first  indications  of  the  disease  are  observed 
in  a  large  percentage  of  cases  at  the  age  of  puberty. 

General  anaemia,  hemorrhage,  digestive  derange- 
ments, and  in  fact  all  causes  which  lower  the  nutri- 
tion of  the  central  nervous  system  may  give  rise  to 
hysteria. 

All  depressing  emotions,  such  as  conjugal  jeal- 


-  69  - 

ousy,  dread  of  pecuniary  embarrassment,  sudden 
fear  and  protracted  anxiety  may  induce  the  affection. 

Contusions,  even  when  of  apparently  trivial  im- 
port, may  cause  the  disease  in  those  of  neurotic  con- 
stitution; and  the  concussion  incident  to  railway  and 
other  accidents  may  cause  an  outbreak  of  hysterical 
symptoms  in  men  and  women  alike.* 

I  have  recently  had  under  my  care  a  gentleman 
who  met  with  a  severe  accident  on  the  Long  Branch 
Railway,  and  in  whom,  in  addition  to  other  symptoms 
of  concussion,  these  hysterical  symptoms  were  a 
prominent  feature.  While  sitting  in  my  office  he 
would  suddenly  shed  tears  without  the  slightest  ap- 
parent provocation;  but  in  an  *  equally  short  space  of 
time  his  weeping  would  be  transformed  into  laughter. 
When  interrogated  as  to  the  cause  of  these  manifesta- 
tions, he  could  assign  no  reason,  affirming  in  the  most 
emphatic  manner  that  the  weeping  and  laughter  were 
alike  entirely  involuntary. 

Imitation  is  a  powerful  exciting  cause  of  the  dis- 
ease in  those  of  impressionable  constitution;  it  is  thus 
that  the  "  epidemics  "  of  hysteria  in  recent  and  ancient 
times  are  to  be  accounted  for. 


*  Vide  "  On  the  Concussion  on  the  Spine,  Nervous  Shock 
and  other  Obscure  Diseases  of  the  Nervous  System,"  by  John 
Eric  Erichsen,  F.  R.  S.,  etc..  New  York,  1S82.  Also,  "In- 
juries of  Nerves  and  their  Consequences,"  London,  1872.  And 
"Lectures  on  Diseases  of  the  Nervous  System,"  by  F.  E. 
Anstie,  The  Lancet,  vol.  ii,  1872. 


—    -JO    — 

In  a  large  percentage  of  cases  hysteria  makes  its 
appearance  between  the  ages  of  fifteen  and  twenty- 
one;  though  idle  and  vicious  modes  of  living  may 
cause  it  to  appear  in  children  under  ten  years  of  age. 

A  factor  of  great  importance  in  the  causation  of 
the  disease  is  masturbation,  which  is  far  more  preval- 
ent among  girls  than  is  commonly  imagined.  The 
practice  appears  to  be  far  more  prolific  of  the  disease 
when  indulged  in  by  females  than  by  males.  I  have, 
however,  seen  two  cases  of  the  affection,  both  occur- 
ring in  men  over  thirty-five  years  of  age,  w^hich  were 
directly  attributable  to  this  vice. 

Pathology. — Post-mortem  examinations  of  the 
nervous  systems  of  hysterical  persons  have  revealed 
absolutely  no  lesion  which  may  be  considered  as 
characteristic  of  the  affection.  About  all  that  we  can 
do  is  to  submit  the  various  symptoms  of  the  affection 
to  analytical  inspection,  and  thereupon  construct  as 
consistent  a  theor}^  as  we  are  able  respecting  their 
origin.  In  this  attempt  the  physiology  of  the  nervous 
system  will  certainly  prove  our  most  valuable  guide. 
Following  this  line  of  thought,  it  is  evident  in  the  first 
place,  that  the  greater  part  of  the  mental  manifesta- 
tions of  the  affection  are  to  be  regarded  as  the  natural 
outgrowth  of  the  volitional  paralysis  and  intellectual 
torpor,  which  are  such  characteristic  features  of  the 
disease.  For  we  find  that,  as  soon  as  the  will  and  the 
purely  intellectual  faculties  in  hysterical  persons  are 
developed  by  proper  methods,  the  abnormally  active 


—  71  — 

emotions  are  brought  under  subjection  and  there  is 
immediate  mental  improvement.  The  essential  psy- 
chological picture  in  hysteria  is  indeed  but  a  complex 
of  riotous  emotions.  Again  the  spasmodic  phenomena 
of  the  affection  may  be  accounted  for  by  assuming  an 
inordinate  explosiveness  of  certain  motor  areas  of  the 
cortex,  while  the  hypersesthetic  manifestations  are 
easily  accounted  for  if  we  admit  a  corresponding 
irritability  of  the  sensory  districts. 

On  the  other  hand,  abolition  of  irritability  in  cer- 
tain motor  fibres  of  the  brain  and  cord  might  perhaps 
account  for  the  paralysis;  while  the  anaesthetic  symp- 
toms might  with  equal  propriety  be  ascribed  to  loss  of 
irritability  in  some  portion  of  the  sensory  tract. 

It  is  evident,  therefore,  from  the  foregoing,  that 
most  of  the  phenomena  of  hysteria  may  be  accounted 
for,  if  we  admit  that  in  this  affection  cortical  irrita- 
bility is  sometimes  exaggerated  and  sometimes  unduly 
diminished  or  even  totally  suppressed. 

I  am  fully  aware  that  the  foregoing  theory  is  open 
to  criticism,  but  nevertheless,  on  the  whole  it  appears 
to  be  the  most  consistent  which  can  be  constructed  in 
the  present  state  of  knowledge.  Jolly*  has  expressed 
views  with  regard  to  the  pathology  of  the  affection, 
which  agree  in  many  respects  with  those  above 
enunciated;  and  the  same  may  be  said  of  the  theory 
elaborated  by  Ross.f 


*Op.  cit.,  p.  ^qoetseq. 
t  Op.  cit.,  p.  862. 


—  72  — 

All  theories  which  seek  to  explain  the  phenomena 
of  the  disease  on  the  assumption  of  changes  in  the 
peripheral  nerves  are  so  manifestly  inadequate  that 
they  require  no  discussion. 

Diagnosis. — Much  might  be  and  has  been  said  re- 
garding the  various  rules  to  be  observed  for  the  pur- 
pose of  differentiating  hysteria  from  the  host  of  dis- 
eases which  it  simulates.  Many  of  those  axioms  are, 
however,  far  from  infallible,  as  most  physicians  of 
large  experience  can  testify.  We  shall,  therefore,  ab- 
stain from  treading  the  quicksands  of  these  logical 
mazes,  and  shall  content  ourselves  instead  with  a  few 
practical  suggestions  of  more  or  less  universal  applica- 
bility. 

The  most  weighty  diagnostic  evidence  of  hysteria 
is  unquestionably  afforded  by  the  characteristic  psy- 
chical conduct  of  the  patient.  If  the  patient  develop 
extreme  mental  irritability  in  the  absence  of  all  excit- 
ing causes  from  without,  if  she  has  lost  volitional  con- 
trol, if  her  intellectual  faculties  are  devoid  of  vigor,  if 
she  is  morbidly  hilarious  and  lachrymose  by  turns,  if 
she  evinces  an  abnormal  and  continuous  craving  for 
sympathy,  and  if  she  resorts  to  various  modes  of  de- 
ception to  obtain  the  latter,  we  may  be  reasonably 
sure  that  we  have  to  do  with  a  case  of  hysteria. 

The  certainty  of  diagnosis  is,  moreover,  greatly 
enhanced  if,  in  addition  to  the  foregoing,  globus  and 
some  of  the  characteristic  sensory  and  motor  derange- 
ments are  present. 


—  73  — 

When  the  local  manifestations  of  the  disease  are 
the  prominent  feature,  the  most  careful  physical  ex- 
amination of  the  affected  part  should  be  undertaken 
in  conjunction  with  the  general  investigation.  We 
have  already  alluded  to  this  point  when  discussing 
hysterical  joint  affections. 

The  determination  of  the  true  nature  of  an  hys- 
terical attack  is  usually  simple  in  uncomplicated  cases, 
especially  if  the  previous  history  of  the  patient  be  ac- 
cessible. In  the  more  complex  phases  of  the  disease, 
however,  it  is  often  impossible,  to  differentiate  the  at- 
tack from  the  seizure  of  true  epilepsy.  This  point  has 
been  discussed  under  the  head  of  hystero-epilepsy. 

Hysteria  is  indeed  a  dexterous  counterfeiter  of 
other  diseases,  but,  like  most  dissemblers,  her  falsifica- 
tions will  not  stand  the  test  of  analysis. 


CHAPTER  X. 

PROGNOSIS— TREATMENT.   • 

Prognosis. — In  cases  of  long  duration,  with  a  pre- 
vious neurotic  history,  the  prospects  of  recovery  are 
decidedly  unfavorable;  this  is  especially  so  when  the 
psychical  disturbances  are  persistent  and  permanent  in 
character.  On  the  other  hand,  even  violent  transitory 
mental  disturbances  are  not  necessarily  of  bad  omen 
as  regards  eventual  recovery  from  the  purely  hysterical 
symptoms;  but  it  is  unfortunately  true  that  these 
attacks  of  insanity  are  liable  to  leave  an  ineffaceable 
trace  behind  in  the  form  of  psychical  weakness,  and 
even  complete  dementation. 

When  the  disease  is  of  short  duration  and  the 
result  of  psychical  infection  (by  imitation)  the  prog- 
nosis is  favorable,  provided  that  the  subject  can  be 
properly  isolated  and  placed  under  appropriate  treat- 
ment. 

Again,  when  manifest  physical  debility  is  the 
demonstrable  cause  of  the  disease,  reinvigoration  by 
forced  feeding  and  rest  often  yields  suprising  results. 
It  must  be  admitted,  however,  that  the  danger  of  re- 
lapse is  always  more  or  less  great,  unless  the  subject 
can  be  properly  protected  from  the  ill-directed  sym- 
pathy of  over-zealous  friends. 

Fore-warned    is,  however,  fore-armed,  and  if   the 


—  75  — 
physician,  realizing  his  personal  responsibility  in  the 
case,  presents  a  true  picture  of  the  possible  dangers 
of  excessive  sympathy  to  the  friends  and  family  of 
the  patient,  much  future  difficulty  and  annoyance  may 
be  avoided. 

Treatment. — The  proper  management  of  hysteri- 
cal cases  is  one  of  the  most  complicated  problems  in 
the  whole  range  of  medicine.  In  the  first  place,  owing 
to  the  imitative  qualities  of  the  affection,  the  conscien- 
tious practitioner  has  much  difficulty  to  persuade  him 
self  that  he  is  really  confronted  by  a  true  pathological 
condition,  and  that  he  is  not  the  victim  of  deception 
pure  and  simple.  The  fact  that  hysterical  women  are, 
of  all  others,  most  prone  to  prevarication  of  all  kinds, 
lends  force  to  his  scepticism.  As  a  result  of  this  un- 
certainty of  mind  the  efforts  of  the  attending  physician 
are  characterized  by  a  perfunctory  observance  which 
is  apt  to  dispel  the  confidence  of  patients  and  friends 
alike.  It  is  therefore  necessary,  above  all  things,  to 
evoke  confidence  on  the  part  of  the  patient.  This  is 
best  accomplished  by  the  adoption  of  a  manner  ex- 
pressive of  firmness,  but  not  necessarily  devoid  of 
feeling.  Above  all  things,  anything  approaching  ex- 
aggeration of  manner  should  be  carefully  avoided.  If 
the  physician  be  called  during  the  progress  of  an 
hysterical  attack,  he  should  avoid  alarming  the  friends 
of  the  patient  by  abrupt  or  unnecessarily  harsh  injunc- 
tions.    A  very  good  mode  of  procedure  is  as  follows: 

Cause  the  patient  to  be  held  firmly  by  those  pres- 


-  76  - 

ent,  in  such  a  manner  that  she  is  prevented  from 
throwing  herself  about  in  a  violent  and  aimless  man- 
ner. Then,  having  loosened  her  clothing,  particularly 
about  the  throat  and  neck,  cold  water  may  be  dashed 
upon  the  face  until  there  is  undoubted  evidence  that 
the  paroxysm  is  over.  This  is  an  old  but  effective  ex- 
pedient. Again,  a  towel  may  be  dipped  in  cold  water 
and  the  face  of  the  patient  submitted  to  a  species  of 
mild  flagellation.  Or,  the  nose  and  mouth  of  the 
patient  may  be  held  closed  so  as  to  interrupt  breath- 
ing— a  very  effective  method  of  bringing  the  attack  to 
a  speedy  termination.  Should  a  faradic  battery  be  at 
hand  the  patient  may  be  treated  with  the  wire  brush. 
Care  should  be  observed,  however,  not  to  employ  cur- 
rents of  too  great  intensity.  Carter  has  laid  down  the 
following  rules  for  treating  the  attack: 

"  The  attacks  will,  in  all  probability,  occur  during 
d  meal,  or  when  there  are  strangers  present,  or  at  some 
inconvenient  time  and  .place,  and  it  may  on  this  ac- 
count be  necessary  to  have  the  patient  removed  to  her 
bedroom.  In  such  case  she  should  be  carried  there 
as  quickly  as  possible,  placed  upon  the  floor,  and  im- 
mediately left  quite  alone,  the  door  being  shut,  and 
no  one  being  suffered  to  open  it  on  any  pretext  what- 
ever until  the  patient  does  so  herself.  But  if  the  room 
in  which  the  attack  takes  place  can  be  spared  for  a  few 
hours,  it  should  be  cleared  and  shut  up  in  the  same 
manner,  and  in  either  case  especial  care  must  be 
taken    not    to    give    utterence    to    a  single  expres- 


—  77  — 
sion  either  of  sympathy  or  alarm.  After  the  lapse 
of  a  longer  or  shorter  time,  often  at  a  meal,  and 
sometimes  not  until  the  next  morning,  she  will 
present  herself  as  usual,  and  will  perhaps  offer  some 
apology,  or  express  some  regret  for  her  illness.  This 
should  be  graciously  received;  and  then  every  attempt 
on  her  part  to  return  to  the  subject  must  be  carefully 
and  industriously  foiled,  no  inquiries  being  made 
about  her  health,  and  all  complaints  being  interrupted 
by  the  introduction  of  ordinary  conversational  topics." 

The  inhalation  of  chloroform  has  been  proposed 
with  a  view  to  aborting  the  attack,  and  in  severe  cases 
some  excellent  results  have  been  reported.  Hypoder- 
mic injections  of  morphia  and  injections  of  opium 
have  also  been  advocated  for  the  same  purpose.  Ex- 
cept, however,  in  very  severe  attacks,  these  potent 
remedies  should  be  discarded  in  favor  of  the  more 
simple  and  available  means  already  referred  to. 

In  France  the  hystero-epileptic  phase  of  attack  is 
much  more  common  than  with  us,  and  in  this  con- 
dition Jolly  has  seen  good  results  from  large  doses  of 
the  bromide  of  potassium  in  this  tetanic  manifestation 
of  the  affection. 

In  very  rare  cases  there  is  a  spasm  of  the  glottis, 
during  the  attack,  of  sufficient  intensity  to  cause  grave 
apprehension.  Under  these  circumstances  a  sponge 
saturated  with  chloroform  or  ether  may  be  held  over 
the  mouth  and  nose  of  the  patient;  or,  the  physician 
may  pass  his  finger  below  the  eppiglottis  and   draw  it 


-  78  - 

upwards.  The  latter  expedient  will,  however,  rarely 
be  required.    So  much,  then,  for  the  hysterical  seizure. 

But  what  of  the  fully  developed  disease;  what 
shall  we  do  to  overcome  the  multiform  manifestations 
of  the  hysterical  state  ?  To  begin  with  the  state  of 
the  patient  in  general,  we  must  endeavor  to  ascertain 
some  peccant  physiological  feature  which  will,  in  a 
measure,  account,  or  at  all  events  tend  to  perpetuate, 
the  unstable  condition  of  the  central  nervous  sys- 
tem. Undoubtedly  a  most  common  feature  of  this 
sort  is  general  anaemia.  The  best  method  of  combat- 
ing this  state  of  bloodlessness  when  it  exists  in  a 
hysterical  person  is  by  appropriate  tonics,  and,  above 
all  things,  by  feeding  and  passive  exercise.  Should 
there  be  an  inordinate  accumulation  of  fat  as  well  as 
lack  of  blood,  we  should  prescribe  massage,  general 
faradization,  and  plenty  of  fresh  air.  Weir  Mitchell 
has,  perhaps,  understood  these  matters  as  well  as  any 
recent  medical  writer.  To  the  medical  man  who  is 
unacquainted  with  this  gifted  writer's  contributions 
to  the  subject  of  physiological  alimentation,  there 
remains  for  exploration  fascinating  chapters  in  scien- 
tific literature. 

States  of  plethora  are  far  more  rare  in  hysteria 
than  those  of  sanguineous  impoverishment.  A  failure 
to  recognize  this  fact  led  among  the  older  physicians 
to  an  incredible  amount  of  blood-letting  and  other  de- 
pleting measures.  As  a  consequence  of  such  mistaken 
treatment,    many    hysterical    persons   were   doubtless 


—  79  — 
forced  into  a  condition  of  premature  decline,  in  which 
the  outcome  was  not  infrequently  fatal  to  life  itself. 
In  the  eyes  of  modern  physiology  all  this  seems  in- 
credible enough,  and  it  must  indeed  be  conceded  that, 
if  we  have  not  arrived  at  perfection,  we  are,  at  least, 
far  ahead  of  the  preceding  generation  of  physicians  in 
the  management  of  many  phases  of  hysteria. 

The  relation  of  affections  of  the  genital  organs 
to  hysterical  symptoms  is  a  question  which  is  liable  to 
be  presented  to  every  practitioner  who  is  brought 
■  much  in  contact  with  the  manifold  neuroses  which 
constitute  such  a  baneful  feature  of  the  lives  of  women 
residing  in  great  cities. 

Most  authors  who  have  written  on  hysteria  are 
accustomed  to  devote  much  space  and  ingenuity  to  a 
discussion  of  this  interesting  conjunction  of  symptoms. 
To  me  all  this  seems  a  useless  waste  of  energy.  In 
the  first  place,  I  have  seen  many  women  suffering 
from  hysterical  symptoms,  in  whom  the  reposition  of 
a  displaced  uterus,  or  the  sewing  up  of  a  lacerated 
cervix  brought  no  relief  so  far  as  the  neurotic  manifes- 
tations were  concerned.  On  the  other  hand,  I  have  seen 
such  persons  improve  in  a  most  wonderful  way  under 
treatment  by  hyper-nutrition,  massage,  Franklinization, 
and  appropriate  moral  restraint.  By  moral  restraint  I 
mean  removing  the  patient  from  the  vicinity  of  friends 
and  family,  so  that  there  is  no  danger  of  subjecting 
the  patient  to  the  highly  prejudicial  influence  of  ill- 
advised  sympathy. 


—  8o  — 

Among  the  remedies  which  have  been  largely  em- 
ployed by  physicians  in  former  times  in  the  treatment 
of  hysteria,  I  would  mention  galbanumand  asafoetida. 
Since,  however,  modern  physiological  research  has 
made  itself  more  generally  felt  in  practice,  the  tend- 
ency to  rely  upon  the  specific  action  of  remedies  of  all 
kinds  has  grown  progressively  less.  This  applies  with 
particular  force  to  hysteria,  where,  as  we  have  seen, 
general  hygienic  measures  are  asserting  themselves 
more  and  more.  Among  the  therapeutic  measures  of 
most  uniformly  good  effect  is  the  cold  douche  or 
sponge  bath.  It  may  be  employed  where  there  is  an 
absence  of  manifest  debility,  and  should  always  be  im- 
mediately followed  by  vigorous  frictions. 

The  anaesthetic  manifestations  of  hysteria  may  be 
treated  with  advantage  by  daily  applications  of  Farad- 
ism,  or,  still  better,  Franklinism.  The  application  of 
metals,  magnets,  and  the  like,  as  recommended  by 
certain  French  physicians,  has  no  other  advantage 
than  the  appeal  which  such  devices  inevitably  make 
to  the  titanic  imaginative  powers  of  the  patient.  To 
me  there  is  a  kind  of  mediaeval  quackery  about  such 
expedients,  which  has  given  rise  to  a  feeling  of  repug- 
nance that  I  am  quite  unable  to  overcome.  I  am  quite 
willing  to  thus  avow  my  scepticism  in  the  presence  of 
the  general  alchemistic  state  of  the  whole  quuestion  of 
metallotherapy. 

Narcotics  and  even  ansesthetics  may  be  resorted 
to    in    combating    the    hyperaesthesia    and    neuralgia 


which  are  such  a  tormenting  comphcation  of  many 
hysterical  cases. 

As  to  the  hysterical  headaches  frequently  met 
with,  bromo-caffein,  inhalation  of  the  nitrite  of  amyl, 
the  bromides,  and  chloral,  in  considerable  doses,  will 
be  found  useful. 

Where  paralytic  complications  are  a  marked  fea- 
ture, electricity,  particularly  the  static  and  faradic 
varieties,  should  be  persistently  and  systematically 
employed.  On  the  other  hand,  when  we  have  to  do 
with  spasms,  as  for  instance  in  persistent  globus^  the 
constant  galvanic  current  may  be  employed  with  ad- 
vantage. Alternate  hot  and  cold  applications  also 
frequently  render  good  service.  When  the  spasm  is 
limited  to  the  stomach  syphonage  with  hot  water  may 
be  resorted  to,  provided  that  the  introduction  of  the 
tube  is  attainable  without  too  much  nervous  shock 
to  the  patient.  In  order  to  facilitate  the  entrance  of 
the  tube  into  the  larynx,  and  to  prevent  spasm  in  the 
latter,  I  have  found  the  painting  of  the  pharynx  with 
cocaine,  and  the  projection  of  a  fine  spray  of  a  strong 
solution  of  the  latter  into  the  upper  air  passages,  an 
excellent  expedient. 

When  there  is  spastic  or  paralytic  retention  of 
urine,  no  hesitancy  should  be  exhibited,  the  catheter 
being  at  once  called  into  requisition.  In  spraying  the 
upper  air  passages,  as  above  described,  I  have  inci- 
dentally observed  that  a  severe  attack  of  globus  may 
sometimes  be   arrested  in  this  manner.     This,  then,  is 


—    82     — 

a  brief  sketch  of  the  resources  at  our  disposal  in  the 
treatment  of  this  most  paradoxical,  aggravating,  ob- 
stinate,  and  obscure  neurosis. 

As  a  matter  of  course  the  thousand  and  one  little 
exigencies  liable  to  arise  in  the  course  of  protracted 
treatment  cannot  be  separately  treated  in  a  work  of 
this  kind.  Enough  that  we  have  given  an  outline  of 
the  policy  to  be  pursued  in  the  treatment  of  the  cases 
most  commonly  met  with.  After  all  has  been  said 
which  can  reasonably  be  said,  it  must  in  truth  be  ad- 
mitted that  the  personal  ascendency  which  the  physi- 
cian is  able  to  gain  over  his  patient  must  ever  consti- 
tute one  of  the  most  important,  if  not  the  supremely 
important,  factor  of  successful  treatment. 


EPILEPSY. 


CHAPTER  I. 

CLASSIFICATION.— SYMPTOMATOLOGY.  — SYMP- 
TOMS WHICH   IMMEDIATELY    PRECEDE 
THE  ATTACK.— AUR/E  EPILEPTIC/E. 

In  its  typical  manifestations  epilepsy  is  charac- 
terized by  phenomena  indicative  of  disordered  sensa- 
tion, motion,  and  intelHgence.  These  derangements 
succeed  each  other  in  the  severe  forms  of  the  disease 
simultaneously  and  suddenly;  in  the  milder  cases  in 
a  certain  rhythmical  succession,  where,  as  in  the 
least  grave  variety,  only  one  class  of  symptoms  is 
represented. 

It  is  customary  to  divide  the  phenomena  of  the 
disease,  according  to  the  nature  of  the  paroxysm,  into 
epilepsia  gravior  or  grand  mal,  and  epilepsia  mitior  or 
petit  mal.  Besides  these  principal  divisions,  which 
serve  to  denominate  the  more  extreme  and  obvious 
forms  of  the  disease,  recent  writers  have  recognized 
certain  transitional  and  irregular  varieties  of  the  affec- 
tion, which,  in  their  turn,  have  received  a  classification, 
albeit  more  or  less  arbitrary. 

In  the  following  description    we    shall    consider 


—  84  — 

the  phenomena  of  the  paroxysm  under  these  head- 
ings: 

1.  Grand  mal,  that  variety  of  the  affection  in 
which  the  seizure  is  characterized  by  coma  and  gen- 
eral convulsions. 

2.  Petit  mal,  that  form  of  the  disease  in  which 
the  paroxysm  is  alone  characterized  by  loss  of  con- 
sciousness, the  convulsive  condition  of  the  voluntary 
muscles  being  absent. 

3.  Epilepsy  characterized  by  partial  impairment 
of  consciousness  and  circumscribed  muscular  spasms. 
This  group  constitutes  a  connecting  link  between  the 
first  two  varieties  of  the  disorder. 

4.  Irregular  forms  of  the  attack. 
Symptoffiatology . — We  may  divide  the  symptoms  of 

epilepsy  into  (i)  such  as  precede  the  paroxysm,  (2) 
such  as  occur  during  the  paroxysm,  and  (3)  such  as 
are  observable  during  the  intervals  of  the  attacks.  In 
the  following  description  we  shall  follow  in  many  re- 
spects the  admirable  classification  of  the  phenomena 
of  the  disease  adopted  by  Nothnagel,  a  writer  whose 
clear  clinical  insight  is  only  equaled  by  his  masterly 
experimental  researches  upon  the  pathology  of  this 
most  interesting  disorder. 

-Premonitory  Syjfiptoms. — These  may  be  divided 
into  such  as  give  warning  of  an  impending  attack  some 
hours  or  days  before  its  occurrence,  and  such  as  im- 
mediately precede  the  seizure — the  so-called  mim 
epilepticce.      The  distant  premonitions  usually  assume 


-  85  - 

the  character  of  mental  disturbances  in  the  form  of 
irritability,  loss  of  memory,  confusion  of  ideas,  and 
unusual  depression  or  exaltation,  vertigo,  and  head 
pains. 

Symptoms  ivhich  immediately  precede  the  Attack: 
Attrce  EpilepticcB. — The  aura  may  affect  the  sensory, 
vaso-motor,  secretory,  motor,  and  psychical  functions. 

In  a  considerable  proportion  of  cases  the  subject 
is  able  to  give  from  memory  an  account  of  the  aura 
which  preceded  the  attack.  Sometimes,  however,  con- 
sciousness is  affected  so  suddenly  that  the  patient  re- 
tains but  a  shadowy  recollection  of  the  occurrences 
which  immediately  preceded  the  seizure. 

The  immediate  prodromes  occur  more  frequently 
and  exhibit  greater  variety  than  the  remote  warnings; 
indeed  they  possess  such  multifarious  characteristics 
that  any  attempt  at  exhaustive  enumeration  of  the 
phenomena  would  necessarily  be  at  once  imperfect 
and  unnecessary. 

In  the  following  description,  therefore,  we  shall 
simply  aim  at  giving  a  general  account  of  the  charac- 
teristics of  these  premonitory  symptoms,  trusting  to 
the  individual  experience  of  the  reader  to  amplify 
his  acquaintance  with  this  interesting  class  of  mani- 
festations. 

The  setisory  aura  consists  in  tickling  sensations, 
or  burning,  lacerating  pains,  which  usually  begin  at 
the  extremity  of  a  limb,  in  the  toes  and  fingers,  and 
extend  upward  toward  the  breast  and  head.      Some- 


—  86  — 

times,  on  the  contrary,  a  loss  of  sensation  is  experi- 
enced in  circumscribed  localities,  such  as  a  portion  of 
a  limb,  or  one  side  of  the  face.  This  diminution  of 
sensibility  may  often  be  recognized  by  the  aid  of  the 
sesthesiometer,  or  by  thermic  tests.  Again,  in  a  certain 
percentage  of  cases,  the  subject  complains  of  isolated 
pains  in  the  head,  either  at  the  vertex  or  upon  one  side 
of  the  cranium. 

Vaso-motor  disturbances  manifest  themselves  by 
sudden  redness  or  pallor  of  the  affected  localities. 
These  circulatory  disturbances  are,  moreover,  often 
preceded  by  sensations  of  burning,  numbness,  or  by  a 
chill,  which,  beginning  in  the  fingers  and  toes,  creeps 
up  the  spine  toward  the  head  and  shoulders. 

Acting  upon  the  observation  that  in  certain  cases 
the  vaso-motor  prodromes  assume  an  unusual  degree 
of  prominence,  recent  authors  have  sought  to  dis- 
tinguish a  separate  variety  of  the  affection,  the  so- 
called  epilepsia  vasomotoria.  There  is  evidently,  never- 
theless, but  scant  justifications  for  such  a  classification, 
inasmuch  as,  if  we  recognize  an  epilepsia  vasomotoria, 
we  are  equally  compelled  to  distinguish  a  large  number 
of  sub-varieties  of  the  affection,  according  to  whether 
the  prodromes  are  characterized  by  a  predominance 
of  this  or  that  special  symptom.  It  is  evidently  more 
logical,  therefore,  to  abstain  from  attempting  to  estab- 
lish further  subdivisions  of  the  disease  on  the  score 
of  any  mere  peculiarity  of  the  aura. 

The  vertigo  and  faintness  often  observed    as  a 


—  87  - 

forerunner  of  the  paroxysm  are,  doubtless,  attri- 
butable to  disturbances  of  the  vaso-motor  condi- 
tions of  the  cerebral  circulation,  and  not,  as  some 
authors  maintain,  to  dilatation  of  the  abdominal 
vessels. 

The  secretory  aura  manifests  itself  in  an  inordinate 
secretion  of  tears,  perspiration,  or  saliva.  Saliva- 
tion is  indeed  often  enough  observed,  whereas 
unusual  activity  of  the  lachrymal  glands  is  more 
rarely  met  with.  Nothnagel  has  frequently  remarked 
profuse  perspiration  as  an  immediate  precursor  of  the 
attack. 

AurcB  of  the  Special  Senses. — The  auras  of  hearing 
consist  of  buzzing,  roaring,  barking,  hissing,  and  ring- 
ing. Sometimes  sepulchral  voices  are  heard  calling 
in  a  strange  and  unintelligible  manner,  or  warning  the 
subject  of  impending  doom.  At  times  also  low,  musi- 
cal sounds  are  heard,  which  may  be  gay  or  melancholy 
in  character.  A  patient  of  mine  complained  that  im- 
mediately before  the  attack  he  heard  the  notes  of  a 
dirge,  ''and  then  all  was  darkness." 

Where  the  aurse  are  visual,  the  phenomena  con- 
sist in  colors,  flashes  of  light,  and  balls  of  fire.  In 
some  cases  the  subject  finds  himself  surrounded  by 
grotesques  or  awful  shapes,  which,  with  outstretched 
claws,  leer  at  and  mock  him.  In  yet  other  instances 
he  conceives  himself  to  be  in  the  midst  of  wild  beasts, 
or  hideous  reptiles,  prepared  at  any  moment  to  devour 
him. 


Aurse  of  the  sense  of  smell  are  usually,  though 
not  always,  of  a  disagreeable  character.  In  some 
cases  the  patient  declares  that  just  previous  to  the  at- 
tack he  is  overwhelmed  by  the  odor  of  dead  animals 
or  cess-pools.  Sometimes,  however,  pleasant  odors, 
such  as  the  perfumes  of  flowers,  are  described. 

The  aurae  of  taste  are  characterized  by  various 
forms  of  perversion.  Sometimes  the  patient  experi- 
ences a  salty  or  metallic  taste;  at  others  a  sensation 
of  sweetness  is  noted,  which  causes  him  to  smack  his 
lips  with  pleasure.* 

The  motor  aura  exhibits  itself  in  various  ways.  In 
a  considerable  percentage  of  cases,  tonic,  or  more  fre- 
quently clonic,  spasms  are  observed  affecting  certain 
groups  of  muscles.  Thus,  one  side  of  the  face  is  fre- 
quently affected  by  the  spasmodic  contractions,  where- 
as in  others  the  spasm  begins  in  the  hand  and  ascends 
to  the  face.  Sometimes  the  muscles  of  the  tongue  are 
involved,  the  subject  becoming  suddenly  speechless. 
In  other  cases,  again,  the  muscles  of  the  eyes  are  im- 
plicated, giving  rise  to  squint.  These  are  the  cases  in 
which  the  subjects  complain  of  double  vision. 

Visceral  Aurce. — These  are  exceedingly  common 
and  consist  of  sensations  of  heat,  cold,  rumbling,  or 
straining  which  are  usually  referred  to  some  organ 
contained  within  the  abdominal  cavity.     The  so-called 


*  Frank,  cited  by  Nothnagel,  has  recounted  an   instance 
of  this  sort. 


epigastric  aura  is  a  sensation  referred  by  the  patient 
to  the  region  of  the  stomach.  The  attack  is  also  pre- 
ceded in  some  cases  by  straining  at  stool  and  on 
urinating. 

The  psychical  aura  is  of  frequent  occurrence,  and 
may  consist  of  an  emotional  disturbance  manifesting 
itself  in  fear  or  disgust,  or  in  derangement  of  the  intel- 
lectual faculties  assuming  the  form  of  confusion  of 
ideas.  It  is  often  very  difficult  to  classify  this  cate- 
gory of  phenomena,  for  the  reason  that  the  description 
given  by  the  patient  is  so  imperfect  as  to  admit  of  no 
certain  conclusions.  Thus,  complaints  are  often  made 
of  a  strange  indescribable  sensation  of  confusion  or 
vacancy,  which  the  patient  recalls  with  evident  diffi- 
culty. These  cerebral  phenomena  should  always  be 
inquired  after  by  the  physician,  as  they  constitute  an 
interesting  and  frequently  observed  type  of  premoni- 
tory symptoms. 


CHAPTER  II. 

THE  MANIFESTATIONS  OF  THE  EPILEPTIC  PAR- 
OXYSM—GRAND MAL 

Epilepsia  Gravior,  or  Grand  Mai. — It  is  custom- 
ary among  most  writers  to  divide  the  epileptic  attack 
into  two  or  even  three  stages.  During  the  first  stage 
of  the  attack  the  patient  lies  in  an  unconscious  con- 
dition, and  his  muscles  are  thrown  into  a  state  of 
tonic  spasm.  Unconsciousness  persists  during  the 
second  period  of  the  paroxysm,  and  at  the  same  time 
the  toxic  contractions  are  succeeded  by  clonic  con- 
vulsions. The  third  period  is  characterized  by  cessa- 
tion of  the  spasms  and  final  restoration  of  conscious- 
ness. 

It  will  be  well  to  consider  somewhat  more  in  de- 
tail these  various  stages  of  the  paroxysm. 

First  Stage. — As  already  noted,  there  is  entire 
loss  of  consciousness  during  this  period  of  the  seizure. 
Sometimes  the  loss  of  volitional  power  is  so  sudden 
that  the  subject  falls  to  the  ground,  as  if  stricken  by 
some  unseen  power.  At  others,  consciousness  disap- 
pears less  rapidly  and  the  patient  is  enabled  to  sink 
upon  a  chair,  lounge,  or  bed,  thus  avoideng  the  danger 
of  falling  against  some  object  which  might  cause  him 
serious  injury.  It  has  frequently  happened,  when  the 
loss  of  consciousness  has  been  sudden,  that  patients 


—   91   — 

have  fallen  against  a  stove  or  even  into  the  fire  itself,  and 
have  thus  sustained  frightful  injuries.  Owing  to  the  pro- 
found coma,  they  feel  not  even  the  remotest  sensation 
of  pain,  and  are  consequently  unable  to  rescue  them- 
selves. When  the  patient  has  been  under  observa- 
tion, great  pallor  of  the  face  has  been  noted,  which  at- 
tains a  maximum  degree  of  intensity  at  the  moment 
the  subject  sinks  into  unconsciousness.  Some  patients 
utter  the  so-called  epileptic  cry  immediately  before 
falling.  This  cry  is  of  so  strange  and  piercing  a  char- 
acter that  animals  and  men  are  frequently  thrown  into 
a  state  of  consternation  upon  hearing  it.  The  feel- 
ings aroused  by  this  cry,  when  heard  among  the  wards 
of  an  insane  asylum,  are  certainly  anything  but  agree- 
able, even  to  those  long  accustomed  to  the  sound. 
During  or  after  the  fall  the  muscular  system  is 
thrown  into  a  condition  of  tonic  spasm.  The  dis- 
tribution of  the  latter  is  subject  to  considerable  varia- 
tion. Sometimes  there  is  opisthotonus;  at  others  but 
one  half  of  the  body  is  involved  and  curvature  takes 
place  in  a  lateral  direction.  In  severe  cases  the 
spasm  is  general,  involving  the  entire  muscular  sys- 
tem. The  muscles  of  mastication  are  violently  con- 
tracted, causing  the  jaws  to  close  with  such  violence 
as  to  break  the  teeth  or  produce  severe  laceration  of 
the  tongue,  should  the  latter  chance  to  be  implicated. 
The  most  varied  and  hideous  distortions  are  produced; 
the  pupils  are  dilated  and  fail  to  react  to  light;  the 
eyeballs  are  deviated  and  the  head  and  neck  are  flexed 


—  92  — 

in  a  backward  direction,  or  rotated  when  the  action 
of  certain  groups  of  muscles  prevails  over  that  of  their 
antagonists.  The  muscles  of  both  the  upper  and 
lower  extremities  are  also  involved.  The  forearm  is 
flexed  or  extended;  the  thumb  and  fingers  are  bent 
into  the  palm;  the  lower  extremities  are  violently  ex- 
tended and  the  foot  is  incurvated.  The  muscles  of 
the  throat  and  those  concerned  in  respiration  are  also 
involved  in  the  spasm,  and  breathing  is  arrested. 
Reflex  action  is  impaired  or  absent  in  many  cases.  As 
already  noted,  the  tonic  contractions  are  not  always  so 
universal  as  the  foregoing  description  would  imply, 
and  in  some  cases  they  involve  certain  groups  of 
muscles  only.  Nor  does  the  paroxysm  always  begin 
with  tonic  muscular  contractions.  Sometimes  these 
are  wholly  wanting,  clonic  spasms  setting  in  at  once. 

Second  Stage. — As  already  noted,  the  prominent 
characteristics  of  this  stage  of  the  attack  are  the  clonic 
spasms,  which  set  in  in  from  two  to  forty-five  seconds 
after  the  inception  of  unconsciousness.  With  the  advent 
of  the  clonic  convulsions  a  remarkable  change  takes 
place  in  the  appearance  of  the  patient.  The  pallid 
aspect  of  the  face  gives  place  to  a  dark,  livid  hue, 
while  at  the  same  time  the  veins  are  seen  to  be 
enormously  distended.  If  the  radial  pulse  is  ex- 
amined at  this  time,  it  will  be  found  to  be  feeble 
or  quite  imperceptible,  though  both  carotids  are 
seen  to  pulsate  violently.  The  majority  of  the  mus- 
cles of  the  head,  trunk,  and  extremities  are  involved 


—  93  — 
in  the  convulsive  seizure.  Owing  to  the  preponderant 
action  of  certain  groups  of  muscles  over  the  corre- 
sponding antagonists,  the  most  remarkable  postures 
are  produced.  In  a  considerable  number  of  cases, 
one  side  of  the  body  is  seen  to  be  more  affected  than 
the  other;  and  this  is  said  to  hold  true  even  in  those 
cases  where  the  convulsions  are  general.*  Sometimes 
the  violence  of  the  spasms  is  so  great  as  to  cause  dis- 
locations, fractures,  and  severe  wounds  of  the  head 
and  extremities.  The  teeth  are  violently  ground  to- 
gether, and  the  tongue,  becoming  implicated,  is 
severely  lacerated.  In  a  large  number  of  cases  the 
patient  is  seen  to  froth  at  the  mouth,  and  the  saliva 
discharged  is  tinged  with  blood  derived  from  wounds 
of  the  tongue  and  raucous  membrane  of  the  mouth. 
At  the  same  time  the  contents  of  the  seminal  vesicles, 
rectum,  and  bladder  may  be  evacuated,  the  contents 
of  the  latter  being  frequently  ejected  with  great  vio- 
lence. 

This  stage  of  the  attack  usually  lasts  from  two  to 
four  minutes;  in  some  instances,  however,  the  clonic 
spasms  persist  five  or  even  ten  minutes.  The  condi- 
tion of  the  pupil  is  variable,  being  sometimes  consid- 
erably dilated,  at  others  contracted. 

Third  Stage. — Usually  a  cessation  of  the  convul- 
sions is  accomplished  gradually,  but  in  exceptional  cases 
the  spasm  ceases  suddenly.     The  spasmodic  contrac- 

*  Nothnagel. 


—  94  — 
tions  grow  less  and  less  and  finally  disappear,  respira- 
tion is  attended  with  less  difficulty,  the  cyanotic 
appearance  of  the  face  is  sensibly  diminished,the  limbs 
become  relaxed,  the  pulse  becomes  stronger,  and  at 
length  consciousness  is  more  or  less  completely  re- 
stored. Sometimes,  however,  the  patient  passes  from 
a  condition  of  semi-consciousness  into  a  deep  sleep, 
and  does  not  awaken  for  hours. 

Westphal  f  has  arrived  at  the  conclusion  that  an 
elevation  of  temperature  after  the  attack  is  rare. 

Williams  |  found  that  the  temperature  might  rise 
as  much  as  3°  F.  after  severe  convulsions. 

The  accounts  given  by  various  authors  as  to 
changes  in  the  composition  of  the  urine  are  conflict- 
ing-i 

After  the  paroxysm  has  subsided  the  subject 
usually  suffers  from  great  physical  exhaustion,  mental 
confusion,  derangement  of  memory,  and  in  rare  in- 
stances from  paresis,  or  hemi-paresis. 


f  "Archiv.  fiir  Psychiatric  und  Nervenkrankheiten," 
vol.  i. 

X  "Medical  Times,"  1867,  vol.  ii. 

II  Vide  Ebstein,  "  Deutsches  Archiv.  fiir  klinische  Medi- 
cin,  vol.  xi. 


CHAPTER  III. 

THE   MANIFESTATIONS  OF  THE  EPILEPTIC  PAR- 
OXYSMS CONTINUED.— PETIT  MAL.— 
SEIZURES  CHARACTERIZED  BY 
LOSS  OF  CONSCIOUSNESS 
AND  LOCAL  SPASMS. 

Epilepsia  Mitioi'  {Petit  Mai). — This  form  of  the 
disease  is  characterized  by  transitory  loss  of  conscious- 
ness, unaccompanied  by  foaming  at  the  mouth,  pulsa- 
tion of  the  carotids,  marked  cyanosis,  or  manifest 
spasmodic  contractions  of  the  voluntary  muscles. 
Persons  subject  to  attacks  oi petit  mat  suddenly  relin- 
quish the  employment  in  which  they  may  happen  to 
be  engaged,  remain  perfectly  motionless  for  a  few 
seconds,  and  then  resume  their  former  occupation.  If 
engaged,  for  example,  in  speaking,  such  persons  sud- 
denly pause  in  the  most  unaccountable  manner  in  the 
middle  of  a  sentence;  but,  after  an  interval  of  a  few 
seconds,  conversation  is  again  resumed.  If  walking 
upon  the  street,  they  suddenly  stop,  but  do  not  usually 
fall,  unless  the  period  of  unconsciousness  should  be 
unusually  long.  In  some  instances,  however,  auto- 
matic actions  are  not  immediately  interrupted,  and  the 
patient  continues  the  occupation  in  which  he  may 
happen  to  be  engaged.  Thus,  musicians  have  been 
known  to  continue  playing   during  an  attack  of  petit 


-  96  - 

nial  without  the  audience  becoming  in  the  sHghtest 
degree  cognizant  of  anything  unusual  in  their  conduct. 

In  the  majority  of  cases  the  aurae  are  entirely 
absent,  or  so  slight  in  character  as  to  escape  the  obser- 
vation or  recollection  of  the  patient.  The  most  com- 
mon warnings  consist  in  flashes  of  light,  darkness 
before  the  eyes,  and  dizziness.  Numerous  sensations, 
already  referred  to  as  constituting  aurse,  may,  it  is 
true,  occur  in  the  entire  absence  of  true  epilepsy.  But, 
when  these  symptoms  occur  with  a  certain  periodicity, 
and  are  accompanied,  moreover,  by  mental  confusion, 
the  suspicion  of  epilepsy  is  justified.  The  diagnosis 
becomes  doubly  sure  if  at  such  times  an  involuntary 
discharge  of  fasces  and  urine  take  place. 

In  a  large  number  of  cases  no  evil  after-effects  are 
observed,  and  the  patient  remains  entirely  oblivious  of 
his  previous  condition.  Sometimes,  however,  even 
when  the  attack  has  been  slight,  symptoms  are  ob- 
served which  are  apparently  entirely  out  of  proportion 
to  the  magnitude  of  the  exciting  cause.  The  patient 
becomes  dull  and  sleepy,  or  suffers  from  headache, 
depression  or  irritability.  Memory  is  also  more  or  less 
impaired,  especially  for  recent  occurrences.  These 
symptoms  often  persist  for  several  hours;  but  they  do 
not  constitute  the  entire  list  of  mental  accidents  to 
which  these  apparently  insignificant  attacks  of  epilepsy 
may  give  rise.  Thus,  the  terrible  disorder  known  as 
epileptic  mania  is  one  of  the  most  common  results  of 
these  mild  attacks  of  epilepsy.  To  this  point  we  shall 
have  occasion  to  refer  hereafter. 


«  —  97  — 

Epileptic  Seizures  Characterized  by  Loss  of  Consci- 
ousness and  Local  Spasm;  Transition  Forms. — This  vari- 
ety of  epilepsy  constitutes  a  veritable  connecting  link 
between  the  major  and  the  minor  forms  of  the  affection. 
In  its  general  characteristics  there  is  a  pronounced  re- 
semblance to  petit  mal,  with  the  addition,  however,  of 
marked  spasmodic  phenomena.  It  rarely  happens 
that  tonic  and  clonic  spasms  set  in  simultaneously,  or 
follow  each  other,  as  in  grand  mal.  In  the  majority  of 
cases,  on  the  contrary,  but  one  or  the  other  form  of 
spasm  is  found  to  exist.  The  location  and  extent  of 
the  spasmodic  phenomena  are  subject  to  considerable 
variation,  and  to  enumerate  all  the  clinical  possibilities 
would  be  next  to  impossible.  Sometimes  the  tongue 
is  rolled  about  from  side  to  side,  while  the  jaws  are 
alternately  opened  and  shut,  as  in  chewing.  In  some 
patients,  on  the  other  hand,  the  attack  manifests  itself 
merely  by  spasm  of  the  facial  muscles,  strabismus,  or 
closure  of  the  eyelids.  Again,  in  a  not  inconsiderable 
number  of  cases  there  may  be  movements  of  the  lips, 
violent  contortions  of  the  muscles  of  the  face,  local 
spasms  in  the  extremities,  or  more  rarely  in  the  trunk, 
and  (according  to  some  writers)  arrest  of  respiration, 
owing  to  spasm  of  the  respiratory  muscles.  Where 
the  spasm  is  located  in  the  extremities  there  is  rigidity 
of  the  same,  or  some  of  the  fingers  or  toes  are  ex- 
tended or  bent,  or,  where  the  convulsions  are  clonic  in 
character,  the  affected  parts  are  moved  backward  and 
forward,   with    a   pendulum-like  motion.     Sometimes 


—  98  —  » 

there  are  clonic  and  tonic  spasms  which  are  more 
general  in  character,  and  which  at  first  sight  would 
suggest  the  major  form  of  epilepsy.  But,  as  a  matter 
of  course,  an  absolutely  sharp  demarkation  between 
the  various  forms  is  not  always  easily  discernible,  and 
it  is  consequently  necessary  to  bear  in  mind  the  rela- 
tive value  of  this  or,  indeed  any  other  classification. 

It  has  been  alleged  by  some  writers  that  the  loss 
of  consciousness  is  by  no  means  absolute  in  this  form 
of  the  seizure.  Nothnagel,  on  the  other  hand,  is  of 
the  opinion  that  in  the  great  majority  of  cases  an  ar- 
rest of  consciousness  takes  place,  which,  although 
often  only  very  transient  is  still  complete. 


CHAPTER  IV. 

MASKED  EPILEPSY. 

Irregular  Forms  of  the  Attack  [Larvated,  or  Mask- 
ed, Epilepsy). — In  this  form  of  the  disease  the  par- 
ox5''sm  is  quite  as  well  marked  as  in  grand  7?ial,  the 
only  difference  being  that,  instead  of  the  violent  con- 
vulsive movements  of  the  latter,  certain  "automatic  " 
mental  and  motor  phenomena  are  evolved,  which, 
though  often  apparently  systematized,  take  place 
while  the  subject  is  in  a  state  of  partial  or  entire  un- 
consciousness. 

The  following  case,  which  occurred  in  my  own 
experience,  is  a  good  illustration  of  this  phase  of  the 
disease: 

A.  v.,  a  young  unmarried  woman,  aged  twenty- 
five  years,  was  brought  to  my  office  about  a  year  ago, 
suffering,  as  her  friends  imagined,  from  the  premoni- 
tory symptoms  of  insanity.  On  inquiry,  I  learned 
that  the  family  history  on  both  the  father's  and 
mother's  side  was  good  so  far  as  the  existence  of 
mental  trouble  was  concerned,  and  the  only  neuro- 
pathic evidence  discoverable  was  afforded  by  the  girl 
herself,  who  complained  of  being  "  nervous  "  and 
"fidgety,"  and  somewhat  lacrymose  and  emotional  at 
times.  These  attacks,  were,  however,  in  no  wise  trace- 
able to  menstruation. 

Upon  examination,  the  organs  of  the  thoracic  and 


abdominal  cavities  were  found  to  be  in  a  healthy  con- 
dition, and,  having  noted  this  fact  in  my  case-book,  I 
was  about  continuing  my  examination  of  the  patient, 
when  suddenly  she  arose  and,  without  the  slightest 
warning,  spat  upon  the  floor,  at  the  same  time 
dropping  her  muff,  which  she  had  been  holding 
in  her  hand.  For  an  instant  after  this  she  stood 
with  an  expression  of  indescribable  horror,  as  if  trans- 
fixed, her  face  meanwhile  wearing  a  chalky  appear- 
ance. In  a  moment,  however,  all  was  over,  and  she 
resumed  her  seat,  as  if  nothing  unusual  had  happened. 
The  mother  of  the  girl,  who  was  present,  began  subse- 
quently to  reprimand  her  in  the  severest  terms, 
at  the  same  time  observing,  with  an  expression  of  ex- 
ultation: "  There,  you  crazy,  nasty  thing,  the  doctor 
has  caught  you  now,  and  he  will  send  you  to  an  insane 
asylum."  Upon  close  questioning,  the  patient  denied 
in  the  most  emphatic  and  convincing  manner  all 
knowledge  of  what  had  occurred,  and  I  am  thoroughly 
persuaded  that  she  told  the  truth.  From  her  mother 
I  learned  that  she  had  formerly  had  many  similiar 
attacks,  during  some  of  which  she  had  shown  a  tend- 
ency to  destructiveness,  breaking  any  object  upon 
which  she  chanced  to  lay  her  hands.  Several  orna- 
ments and  pieces  of  furniture  had  been  destroyed  in 
this  way,  on  account  of  which  she  had  become  very 
unpopular  in  her  family,  the  members  of  which  would 
gladly  have  seen  her  relegated  to  an  asylum,  as  I  soon 
ascertained. 


Sometimes  the  acts  perpetrated  by  persons  suffer- 
ing from  this  masked  type  of  epilepsy  are  far  more 
compUcated.  I  can  recall  a  case  illustrative  of  this 
complex  mental  automatism,  occurring  in  the  family 
of  an  intimate  friend.  The  following  are  the  principal 
points  of  interest  connected  with  this  case: 

C.  E.,  a  neurotic  lad  of  eighteen,  of  delicate 
frame,  came  under  my  observation  some  two  years 
since.  The  principal  reason  for  consulting  me,  as  his 
father  explained,  was  because  the  boy's  "  memory  " 
seemed  to  be  affected,  and  because  of  certain  other 
mental  traits  which  excited  the  apprehension  of  his 
parents  and  teachers.  On  questioning  the  father  of 
the  lad,  I  learned  that  the  latter  was  in  the  habit  of 
running  away  from  school  and  from  his  home,  remain- 
ing absent  sometimes  for  days  at  a  time.  So  annoy- 
ing had  these  frequent  occurrences  become  that  the 
parents  of  the  boy  had  finally  been  induced  to  attach 
a  leathern  placard  to  his  coat  bearing  his  address  as 
well  as  a  request  to  the  police  to  return  him  to  his 
home  when  found.  Indeed,  he  had  been  returned  by 
the  police  on  sundry  occasions;  but  the  most  singular 
part  of  the  transaction  was  the  fact  that  he  denied  in 
the  most  obstinate  manner  all  knowledge  of  his 
singular  peregrinations — a  statement  which  he  reso- 
lutely maintained  in  the  face  of  the  severest  chastise- 
ment. This  was  the  more  remarkable  since  his 
veracity  upon  all  other  topics  was  unquestioned.  On 
examining  the  lad,  I  found  his  back,  ankles,  and  thighs 


covered  with  scars,  which  upon  inquiry  I  learned  were 
the  result  of  inhuman  beatings  received  at  the  hands 
of  his  guardians,  who  considered  him  to  be  at  once  a 
truant  and  a  liar.  With  tears  in  his  eyes  he  declared, 
with  the  most  convincing  sincerity,  that  he  had  no  re- 
collection whatever  of  the  occurrences  for  which  he 
had  been  punished. 

Such  cases  as  this  are  far  more  common  than  is 
generally  supposed,  as  doubtless  most  practitioners  of 
large  experience  can  testify. 


CHAPTER  V. 

"THALAMIC"      EPILEPSY. —  JACKSONIAN       EPI- 
LEPSY.—SENSORY  EPILEPSY. 

Under  the  designation  of  "Thalamic  Epilepsy," 
Hammond*  has  published  an  interesting  case,  the  chief 
characteristics  of  which  are  "  conscious  hallucinations, 
followed  by  unconsciousness,  but  unattended  by  mus- 
cular spasm.  This  form  of  affection  is  comparatively 
rare." 

With  regard  to  the  frequency  of  the  attack,  in 
common  epilepsy  the  greatest  variations  are  ^en- 
countered. Thus,  in  some  cases  a  year  may  elapse 
without  the  appearance  of  a  single  paroxysm,  while 
in  other  cases  the  seizures  may  occur  thrice  or 
even  half  a  dozen  times  daily.  Sometimes,  again, 
they  exhibit  a  well-marked  periodicity,  whereas,  in 
not  a  few  cases  no  kind  of  regularity  is  discern- 
able.  In  yet  another  class  of  cases  the  subject  has 
hardly  time  to  emerge  from  one  convulsive  attack 
before  he  is  beset  by  another,  the  paroxysms  following 
each  other  in  such  rapid  succession  that  there  is  finally 
no  apparent  restoration  of  consciousness  between  the 
seizures.  This  condition  is  known  as  the  status  epilep- 
ticus — a  phase  of  the  disease  which  has  received  con- 
siderable attention  from   French  writers,  notably  from 


*  "On  Thalamic  Epilepsy,"  "Archives  of  Scientific  Med- 
icine," August,  1880. 


—  I04  — 

Bourneville.*  This  writer's  subdivision  of  the  condi- 
tion seems  to  me,  however,  unnecessary.  The  main 
points  to  bear  in  mind  are  that  this  form  of  the  attack 
is,  generally  speaking,  of  graver  import  than  the 
ordinary  seizures,  that  hemiplegia  develops  in  a  con- 
siderable number  of  cases,  that  bed-sores  may  be 
developed  over  the  sacrum,  and  that  finally  a  condition 
of  maniacal  excitement  with  hallucinations,  or  depres- 
sion and  coma,  may  succeed  the  convulsions. 

I  have  seen  cases  in  which  from  twenty  to  fifty 
seizures  occurred  in  the  course  of  twenty-four  hours. 

•  The  arrest  of  these  convulsions  is  immediatel}'' 
attained  by  the  application  of  pressure  to  the  carotids, 
which  is  best  accomplished  with  an  appropriate  instru- 
ment, f 

So-called  "■  Jacksoma7i"  Epilepsy. — There  are  cer- 
tain forms  of  local  or  unilateral  spasm,  occurring 
usually  without  loss  of  consciousness,  which  have  been 
carefully  investigated  by  Dr.  Hughlings   Jackson,  and 


*"  Etudes  clinique  et  thermometriques  sur  les   maladies 
du  systeme  nerveux,"  1873. 

f  "  Prolonged  Instrumental  Compression  of  the  Carotids 
as  a  Therapeutic  Agent,"  by  J.  Leonard  Corning,  M.  D., 
."Medical  Record"  of  February  18,  1882.  Also  "Philadelphia 
Medical  News  "  of  June  17,  1883.  "  Brain  Rest,"  by  J.  Leon- 
ard Corning,  M.  D.,  G.  P.  Putnam's  Sons,  New  York,  1883. 
"Carotid  Compression,"  Anson  D.  F.  Randolph  &  Co.,  New 
York,  1882.  "Brain  Exhaustion,"  by  J.  Leonard  Corning. 
M.  D.,  D.  Appleton  &  Co.,  New  York,  1884. 


—  I05  — 

which,  in  accordance  with  the  views  entertained  by 
that  observer  with  respect  to  their  pathology,  have 
found  a  place  in  medical  literature  under  the  designa- 
tion of  "Jacksonian  Epilepsy."  Since  the  spasms  in 
question  are  almost  invariably  due  to  organic  intra- 
cranial disease,  their  extended  consideration  would  be 
out  of  place  in  a  work  of  this  character.  But,  since 
most  recent  systematic  writers  are  in  the  habit  of 
devoting  some  attention  to  them  in  connection  with 
the  discussion  of  the  pathology  of  epilepsy,  I  have 
decided  to  give  a  brief  sketch  of  their  principal  char- 
acteristics, reserving  their  more  extended  discussion 
for  a  future  occasion.  While  so  doing,  I  can  not,  how- 
ever, refrain  from  protesting  against  the  inconsistency 
of  a  pathology  which  would  designate  phenomena  of 
this  class  as  epileptic.  There  is,  indeed,  no  more 
pathological  similitude  between  these  local  spasms  and 
true  idiopathic  epilepsy  than  exists  between  the  latter 
and  the  contractions  evoked  by  the  electric  current 
when  applied  to  the  motor  centers  in  the  cortex. 

It  is  true  that  Jackson  was  anticipated  by  Bravais* 
as  far  as  the  description  of  these  unilateral  convulsions 
is  concerned,  but  it  was  reserved  for  the  former  clini- 
cian to  thoroughly  elucidate  the  morbid  physiology 
of  the  affection.  The  researches  of  Dr.  Jackson  in 
this  important  field  are  recorded  in  a  series  of  papers, 
which  have  received  a  wide  and  merited  attention. 


*  "  Recherches  sur  les  symptomes   et   le   traitement   de 
I'epilepsis  hemiplegique,"  These,  Paris,  1827. 


—   io6  — 

"Jacksonian  epilepsy"  is  characterized  by  the 
occurrence  of  partial  convulsions,  which  may  be  limited 
to  one  extremity  or  to  one  side  of  the  face,  or  which, 
beginning  in  one  extremity,  may  extend  to  the  other, 
or  even  involve  half  of  the  body.  In  rare  instances 
the  spasm  may  extend  to  the  opposite  side  as  well. 

As  we  have  already  seen,  consciousness  usually 
remains  unaffected,  or,  where  unconsciousness  takes 
place,  it  is  only  evident  toward  the  end  of  the  attack, 
so  that  the  patient  is  afterward  able  to  recall  what  has 
taken  place  before  and  during  the  greater  portion  of 
the  seizure. 

This  form  of  epilepsy  owes  its  origin  to  coarse 
disease  situated  in  or  near  the  cortex.  The  most  fre- 
quent cause  of  the  disease  is  a  syphilitic  gumma,  but 
localised  cicatrices,  wounds,  tubercle,  meningo-ence- 
phalitis,  and  indeed  all  forms  of  circumscribed  irrita- 
tive lesions  of  the  cortex,  may  give  rise  to  the  spasms. 

When  we  consider  the  grave  nature  of  such 
lesions  it  is  not  surprising  that  the  limbs  affected  by 
the  convulsions  may  subsequently  become  the  seat  of 
temporary  or  even  permanent  paralysis.  The  latter 
eventuality  is  prone  to  occur  where  the" lesion,  which 
at  first  may  have  been  merely  irritative  in  character, 
ultimately  destroys  that  portion  of  the  cortex  in  which 
it  is  situated,  or  against  which  it  impinges.  This  as- 
sociation of  the  unilateral  convulsions  with  secondary 
paralysis  has  given  rise  to  the  designation  often  en- 
countered in  medical  literature  of  hemiplegic  epilepsy 


—   I07  — 

("epilepsia  hemipleique  ").  But  why  should  there  be 
convulsions  associated  with  these  profound  cortical 
lesions  ?  Dr.  Hughlings  Jackson's  explanation  of  this 
interesting  pathological  fact  is  at  once  ingenious  and 
plausible.  He  believes  that  the  ganglia  in  the  imme- 
diate vicinity  of  the  lesion  are  kept  in  a  state  of  mor- 
bid irritability,  and  that  consequently  they  are  unduly 
supplied  with  blood.  As  a  result  of  this  hyper-irriga- 
tion, the  ganglion  cells  absorb  an  excessive  amount  of 
nutriment,  so  that  their  superfluous  energy  finds  a 
vent  in  sudden  explosions,  the  products  of  which  are 
the  convulsions.  These  explosions  are  followed  by 
exhaustion  and  inertia  of  the  nerve-centres  involved, 
and  consequent  temporary  paralysis  of  the  previously 
convulsed  muscles  ensues.  As  we  have  already  had 
occasion  to  observe,  however,  irritative  lesions  of  this 
character  may  eventually  destroy  the  motor  centres  in 
the  cortex  near  which  they  chance  to  be  situated,  and 
with  the  result  of  causing  permanent  paralysis  of  the 
muscles  over  which  the  centres  in  question  preside. 

Sensory  Epilepsy. — This  variety  of  the  affection 
has  been  referred  to  by  Sommers  and  others,  and  in  a 
recent  article  Dr.  Allan  McLane  Hamilton*  has 
recorded  several  cases  illustrative  of  the  manifold 
phases  of  this  form  of  epilepsy.    In  the  first  case  there 


*"A  Contribution  to  the  Study  of  Several  Unusual 
Forms  of  Sensory  Epilepsy  which  are  probably  dependent 
upon  Lesions  of  the  Occipital  Cortex,"  by  Allan  McLane 
Hamilton,  M.  D.,  "Medical  Record,"  April  4,  1885. 


—  io8  — 

were  sudden  hemiopia,  supra-orbital  neuralgia,  unila- 
teral anaesthesia  of  extremities,  tongue,  and  gums, 
temporary  speech  disturbance,  and  loss  of  conscious- 
ness. In  another  case  there  were  hemianopsia,  frontal 
headache,  hemianaesthesia,  temporary  mutism,  and 
loss  of  consciousness. 

The  researches  of  Krause,  D.  J.  Hamilton,  Starr, 
Munk,  and  Wernicke  have  done  much  to  shed  light 
upon  the  morbid  physiology  of  these  exceptional 
forms  of  epilepsy;  but,  as  the  discussion  is  still  by  no 
means  closed,  I  shall  refrain  from  entering  further  into 
the  consideration  of  this  interesting  but  obscure  mani- 
festation. 


CHAPTER  VL 

CAUSATION. 

The  most  potent  predisposing  cause  of  epilepsy  is 
probably  found  in  a  hereditary  neuropathic  tendency 
transmitted  from  the  father,  mother,  or  both.  Some- 
times, however,  this  hereditary  tendency  is  not  readily 
discoverable,  owing  to  the  fact  that  one  or  even 
several  generations  have  escaped.  This  circumstance 
accounts,  doubtless,  in  a  measure  for  the  conflicting 
statistics  adduced  in  favor  of  or  against  the  theory  of 
hereditary  influence.  When  carefully  collected  and 
impartially  interpreted,  there  can  be  little  doubt,  how- 
ever, that  statistics  go  far  to  prove  the  great  getio- 
logical  importance  of  heredity  in  this  as  in  other 
neuroses.  It  should  be  borne  in  mind,  in  this  connec- 
tion, that  it  is  not  absolutely  necessary  to  trace  a  series 
of  epilepsies  occurring  in  successive  generations  in 
order  to  prove  a  hereditary  influence.  On  the  con- 
trary, all  that  is  required  is  proof  of  the  existence  in 
the  family  of  a  well-marked  neuropathic  diathesis,  ex- 
perience having  shown  that  such  a  morbid  tendency 
may  exhibit  itself  in  almost  any  form  of  organic  or 
functional  nervous  disease.  Regarding  the  subject 
from    this    standpoint,    Herpin*    found,    out   of  two 


*  "  Du  pronostic  et  du  traitement  curatif  de  I'^pilepsie," 
Paris,  1852. 


hundred  and  forty- three  epileptics,  well-marked  here- 
ditary tendencies  in  forty-three  cases. 

The  cases  reported  by  Petit*  of  healthy  children 
occurring  in  families  in  which  both  parents  were 
epileptic  have  been  cited  as  testimony  calculated  to 
destroy  the  integrity  of  the  theory  of  hereditary  influ- 
ence. They  possess,  however,  no  value  whatever  so 
far  as  the  rebuttal  of  the  evidence  upon  which  that 
theory  is  founded  is  concerned,  since  at  most  such 
facts  only  go  to  show  that  one  or  more  generations 
may  escape  from  the  baneful  pre-natal  influences — a 
fact  already  sufficiently  understood  by  all  medical 
statisticians. 

Echeverria's  opinion  that  phthisis  in  the  parents 
has  a  tendency  to  cause  epilepsy  in  the  offspring  seems 
to  us  well  founded,  though  controverted  by  Noth- 
nagel,f  who  regards  the  association  of  the  two  diseases 
as  explained  by  the  great  frequency  of  phthisis.  The 
fact  that  a  certain  condition  of  instability  of  the  cen- 
tral nervous  system  is  engendered  by  the  malnutrition 
consequent  upon  scrofula,  anaemia,  and  chlorosis,  and 
that  such  an  unstable  condition  often  eventuates  in 
epilepsy,  is  indirect  evidence  of  the  correctness  of 
Echeverria's  position.  Consanguineous  marriages 
also  appear  to  predispose  to  the  occurrence  of  the  dis- 
ease in  the  offspring. 


*Gaz.  med.  de  Paris,"  i8,  i860. 
f  Op.  cit.,  p.  202. 


Alcohol  has  been  considered  an  important  aetio- 
logical  factor,  but  evidence  on  this  point  is  conflicting. 
There  is  no  doubt,  it  is  true,  that  chronic  alcohoUsm 
and  epilepsy  are  frequently  associated;  but  whether 
the  former  is  the  outgrowth  of  the  latter,  or  whether 
the  epilepsy  is  to  be  regarded  as  the  result  of  the 
alcoholic  excesses,  is  difficult  of  determination. 

Age  is  unquestionably  an  important  predisposing 
factor  in  epilepsy.  In  one  hundred  and  thirty-eight 
cases  analyzed  by  myself,  I  found  that  in  25  per  cent, 
the  disease  began  under  eight  years,  in  5 1  per  cent, 
between  eight  and  twenty-five,  in  13.5  per  cent,  be- 
tween twenty-five  and  thirty-five,  and  in  10.5  per  cent, 
between  thirty-five  and  fifty. 

Gower's*  statistics  differ  somewhat  from  my  own; 
but  since  they  were  derived  from  the  analysis  of  a 
larger  number  of  cases,  they  are  perhaps  more  exact. 
Of  1,450  cases  analyzed  by  this  observer,  12.5  per 
cent,  began  during  the  first  three  years  of  life,  29  per 
cent,  under  the  tenth  year,  46  per  cent,  between  ten 
and  twenty,  and  15.7  per  cent,  between  twenty  and 
thirty. 

Sex  has  a  less  obvious  influence  upon  the  occur- 
rence of  the  disease  than  was  formerly  supposed.  The 
older  writers  believed  that  the  disease  was  more  com- 
mon among  males  than  females,  but  their  views  do 


*Vide  "  British  Medical  Journal,"  March  6,  1880,  as  well 
as  subsequent  communications. 


not  seem  to  have  been  derived  from  a  careful  analysis 
of  statistics,  and  are  apparently  nothmg  more  than 
arbitrary  assertions.  As  to  recent  writers,  the  opinion 
is  quite  generally  expressed  that  the  disease  is  more 
frequent  among  males  than  among  females,  while  one 
or  two  observers  believe  that  the  proportion  between 
the  two  sexes  is  about  equal.  For  my  own  part,  I 
have  no  hesitancy  in  expressing  the  belief  that  the 
disease  is  at  least  as  common  among  males  as  among 
females.  Of  72  cases  of  epilepsy  which  I  have  re- 
cently seen  in  asylum,  dispensary,  and  infirmary  prac- 
tice, 41  occurred  in  men  and  31  in  women. 

It  is  possible  that  the  relative  frequency  of  the 
disease  in  the  sexes  may  vary  somewhat  with  age;  but, 
be  that  as  it  may,  there  is  no  doubt  that  in  ordinary 
hospital  practice  the  disease  is  somewhat  more  fre- 
quent encountered  among  males  than  among  females. 

The  factors  which  may  be  classed  as  exciting 
causes  of  the  disease  are  undoubtedly  numerous.  We 
shall,  however,  discuss  only  the  more  frequent  and  im- 
portant of  the  latter,  since  to  attempt  to  enumerate 
them  all  would  be  alike  devoid  of  theoretic  or  practical 
advantage. 

In  former  times  much  importance  was  ascribed  to 
sexual  excesses  in  the  production  of  the  disease;  but 
in  more  recent  times  a  reversal  of  this  decision  is  ap- 
parent in  some  quarters,  so  that  at  the  present  day 
it  is  quite  in  accord  with  fashion  to  undervalue,  and 
even  to  deny  altogether,  the  setiological  importance 
of  this  factor. 


—  113  — 

From  my  own  observations  in  connection  with 
this  matter,  I  can  not  help  believing  that  modern 
writers  have  been  too  hasty  in  their  conclusions. 

It  is  an  undoubted  fact  that  the  great  majority  of 
epileptics  are  addicted  to  the  practice  of  masturbation, 
and  that  the  habit  is  quite  as  prevalent  among  female 
as  among  male  patients.  Many  recent  writers,  never- 
theless, regard  the  vice  as  one  of  the  manifestations 
of  the  disease,  and  not  as  one  of  its  causes.  The 
question  is,  however,  a  difficult  one  to  decide,  and 
arbitrary  assertions  for  or  against  the  proposition  are 
evidently  inadmissible.  But,  after  all,  the  most  im- 
portant question  to  decide  is  not  whether  epileptics 
masturbate  during  the  disease,  on  account  of  the  lat- 
ter, but  whether  they  were  addicted  to  the  vice  pre- 
vious to  the  advent  of  the  epileptic  symptoms. 

Out  of  seventy-two  cases  of  epilepsy  which  I  in- 
vestigated with  regard  to  this  point,  84  per  cent, 
afforded  histories  of  excessive  masturbation  previous 
to  the  first  paroxysm.  In  one  case  localized  spasms 
began  in  the  left  hand,  after  the  practice  had  been 
continued  for  about  three  years,  and  in  course  of  time 
the  convulsions  became  general.  There  were  no  para- 
lytic symptoms,  and  the  patient,  a  young  man  of 
twenty-eight,  denied  having  had  syphilis.  In  the  face 
of  such  evidence,  I  cannot  help  believing  that  we  are 
justified  in  inferring  that  a  causal  connection  really 
does  exist  in  some  cases  between  persistent  masturba- 

9  z 


—  114  — 

tion  and  the  development  of  that  instability  of  the 
central  nervous  system  which  is  so  characteristic  of 
the  epileptic  state.  Cases  in  which  the  first  epilep- 
tic paroxysm  was  developed  during  coitus  certainly 
lend  strength  to  the  argument.  The  conclusion 
is  indeed  inevitable  that  sexual  excesses  constitute  a 
far  more  frequent  predisposing  and  exciting  cause  of 
the  affection  than  is  admitted  by  Nothnagel*  and 
other  excellent  writers. 

'  Epilepsy  is  frequently  evoked  by  such  psychical 

disturbances  as  sudden  fear,  grief,  pecuniary  and  other 
forms  of  anxiety,  and  indeed  by  all  violent  appeals  to 
the  emotional  mechanism.  Such  occurrences  un- 
questionably constitute  some  of  the  prolific  exciting 
causes  of  the  disease;  but  it  is  exremely  problematical 
whether  the  epileptic  symptoms  would  have  been 
evoked  were  the  central  nervous  system  not  already 
in  a  state  of  morbid  receptivity. 

Epilepsy  is  also  prone  to  develop  in  the  course  of 
or  subsequent  to  the  occurrence  of  the  febrile  disturb- 
ances of  infancy.  It  is  also  frequently  developed 
after  injury  to  a  nerve,  or  as  the  result  of  reflex  irrita- 
tion induced  by  teething  and  other  causes. 

Sometimes  the  disease  is  traceable  to  some  cranial 
injury  of  such  apparent  insignificance  that  it  has  been 
speedily  forgotten,  and  only  the  most  careful  inquiry 
serves  to  elicit  the  fact.     This  applies  with  particular 

*  Op.  cit.,  p.  203. 


—  115  — 

force  to  young  children  afflicted  with  local  or  general 
spasms — cases  in  which  we  are  compelled  to  rely  upon 
the  equivocal  testimony  of  nurses  and  other  ignorant 
persons.  Some  of  the  most  severe  cases  of  localized 
epilepsy  (hemi-epilepsy)  which  have  come  under  my 
observation  'occurred  in  young  children  who  had  been 
dropped  by  nurses,  or  had  met  with  some  other  form 
of  accident  at  the  hands  of  servants.  In  all  such  cases 
there  is  probably  always  more  or  less  indirect  injury 
to  the  brain,  with  consequent  development  of  grave 
organic  lesions,  though,  it  is  true,  there  may  be  no  ex- 
ternal indication  of  injury. 

Blows  upon  the  cranium  are  not  liable  to  eventu- 
ate in  epilepsy,  according  to  some  writers,  unless  they 
are  of  sufficient  severity  to  cause  unconsciousness. 
This  appears  to  me  an  altogether  too  sanguine  view  of 
the  matter,  since  I  have  seen  at  least  two  cases  of  epi- 
lepsy in  children  which  developed  soon  after  blows  of 
so  slight  a  nature  as  to  be  almost  forgotten.  There  is 
little  doubt  in  my  own  mind  that  the  most  insignificant 
concussion  about  the  head,  even  when  unaccompanied 
by  evidences  of  abrasion,  may,  sooner  or  later,  develop 
epileptic  symptoms.  This  observation  applies  with 
particular  force  to  infancy  and  early  childhood, 
when  the  non-resistent  character  of  the  cranial  bones 
facilitates  the  transmission  of  sudden  shocks  to  the 
brain. 

Even  where  no  history  of  a  blow  is  forthcoming, 
there  is  strong  presumptive  evidence  that  there  has 


—  ii6  — 

been  contusion  of  some  kind.  Many  cases  of  epilepsy, 
occurring  after  slight  abrasions  about  the  head,  have 
been  ascribed  to  "reflex"  causes;  but  it  is  probable 
that,  in  a  considerable  percentage  of  such  cases,  there 
is  more  or  less  direct  disturbance  of  the  cerebral  sub- 
stance itself,  although  some  time  may  have  elapsed 
before  the  appearance  of  the  first  paroxysms.  In  all 
such  cases  great  care  should  be  exercised  in  forming 
an  opinion,  as  to  causation,  since  the  prognosis  will 
manifestly  be  much  less  favorable  when  the  paroxysms 
are  traceable  to  direct  injury  than  when  they  are 
really  of  reflex  origin. 


CHAPTER  VII. 

EXPERIMENTAL  RESEARCHES. 

The  most  important  experimental  investigations 
relative  to  the  pathogeny  of  epilepsy  are  those  of 
Marshall  Hall,  Sir  Astley  Cooper,  Kussmaul  and 
Tenner,  Landos.  Nothnagel,  Brown-Sequard,  West- 
phal,  Magnan,  Hitzig,  and  Ferrier. 

Before  discussing  the  varfous  theories  of  the  dis- 
ease, which  are  directly  or  indirectly  the  outgrowth  of 
these  investigations,  it  will  be  advisable  to  review  the 
experiments  themselves,  in  order  the  better  to  appre- 
ciate how  much  objective  matter  is  really  embodied  in 
these  hypotheses. 

Even  among  the  ancients  there  is  an  evident  ten- 
dency to  appropriate  the  results  of  the  rough  experi- 
ments at  hand  to  the  elucidation  of  the  theory  of  dis- 
ease. Thus,  Hippocrates*  taught  that  convulsions 
might  arise  as  well  from  fulness  as  from  want  of  blood. 
He  was,  doubtless,  guided  in  these  statements  by  ob- 
servations made  upon  animals  condemned  to  die  in 
the  shambles,  coupled,  perhaps,  with  considerations 
derived  from  practical  experience  at  the  bedside. 
Kellie,f  who  made  a  series  of  experiments  upon  sheep, 
and    Pioray,J    who   conducted   similar   investigations 


*  "Aphorisms,"  sec.  vi,  48. 

fVide  "On  Bloodletting,"  by  Marshall  Hall. 

^''Archives  generales  de  medecine,"  January,  1826. 


—  ii8  — 

upon  dogs,  found  that  copious  blood-letting  was  fol- 
lowed by  convulsions.  Marshall  Hall*  and  Travers 
were,  however,  among  the  first,  if  not  the  first,  to  note 
the  resemblance  between  the  convulsions  produced  by 
rapid  bleeding  in  man  and  other  warm-blooded  ani- 
mals and  the  spasms  of  epilepsy. 

Although,  as  already  noted,  the  ancients  and 
older  medical  writers  had  formed  opinions  relative  to 
the  role  played  by  the  intra-cranial  blood-stream — 
theories  which,  even  at  the  present  day,  bear  evidence 
of  a  high  degree  of  perspicuity — it  is  commonly  con- 
ceded that  the  fundamental  experiments  undertaken 
by  Sir  Astley  Cooperf  in  1831  really  paved  the  way 
for  the  scientific  study  of  epilepsy.  These  experi- 
ments consisted  in  ligation  of  the  vertebral  and  carotid 
arteries;  of  both  carotid  arteries;  of  both  vertebral 
arteries.  Then,  ligation  of  the  carotids  first  and  of 
the  vertebrals  nine  days  afterward;  of  the  carotids  and 
subsequent  compression  of  the  vertebrals;  and,  finally, 
ligation  of  the  vertebrals  and  subsequent  compression 
of  the  carotids. 

Of  these  experiments,  that  in  which  the  carotids 
were  first  ligated,  and  the  vertebral  arteries  immedi- 
ately afterward  compressed,  is  perhaps  the  most  im- 


*  Op.  cit. 

f "  Some  Experiments  and  Observations  on  tying  the 
Carotid  and  Verteoral  Arteries,"  by  Sir  Astley  Cooper. 
"Guy's  Hospital  Reports,"  1836,  vol.  i,  p.  458  et  seq.  The  ex- 
periment, cited  at  length,  is  continued  on  pages  465,  466. 


—   119  — 

portant;  and  I  cannot  therefore  do  better  than  quote 
the  same,  in  the  words  of  Sir  Astley   Cooper  himself: 

"  As  tying  the  vertebral  arteries  is  a  difficult  ex- 
periment, it  occurred  to  me  that  I  might  compress 
them  with  my  fingers,  after  tying  the  carotids,  and 
produce  the  same  effects. 

"I  tied  the  carotid  arteries;  respiration  was  some- 
what quickened,  and  the  heart's  action  increased,  but 
no  other  effect  was  produced.  In  five  minutes  the 
vertebral  arteries  were  compressed  by  the  thumbs,  the 
trachea  being  completely  excluded.  Respiration  al- 
most directly  stopped,  convulsive  struggles  'succeeded, 
the  animal  lost  consciousness,  and  appeared  dead.  The 
pressure  was  removed,  and  it  recovered  with  a  con- 
vulsive inspiration.  It  lay  upon  its  side,  making  vio- 
lent convulsive  efforts,  breathing  laboriously,  and  its 
heart  beat  rapidly. 

"  In  two  hours  it  had  recovered,  but  its  respira- 
tion was  laborious. 

"  The  vertebrals  were  compressed  a  second  time. 
Respiration  stopped;  then  succeeded  convulsive 
struggles,  loss  of  motion  and  apparent  death. 

"  When  let  loose,  its  natural  functions  returned 
with  a  loud  inspiration,  and  with  breathing  excessively 
labored. 

"  In  four  hours  it  was  moving  about  and  ate  some 
greens. 

In  five  hours  the  vetebral  arteries  were  com- 
pressed a  third  time,  and  with  the  same  effect. 


"  In  seven  hours  it  was  cleaning  its  face  with  its 
paws. 

"  In  nine  hours  the  vertebral  arteries  were  com- 
pressed for  the  fourth  time,  and  with  the  same  effect 
upon  its  respiration. 

"  After  thirteen  hours  it  was  lively. 

"  In  twenty-four  hours  the  vertebral  arteries  were 
compressed  for  a  fifth  time,  and  the  result  was  the 
same — namely,  suspended  respiration,  convulsions, 
loss  of  motion  and  consciousness.  On  the  removal  of 
pressure,  violent  and  laborious  respiration  ensued,  and 
afterward  the  breathing  became  very  quick. 

"  After  forty-eight  hours,  for  the  sixth  time,  the 
compression  was  applied,  with  the  same  effect." 

These  experiments  of  Sir  Astley  Cooper  have 
shown,  then,  that  ligature  of  both  carotids  and  simul- 
taneous compression  of  the  vertebrals  give  rise  to  uncoti- 
sciousness,  suspension  of  respiration,  and  convulsions. 

Subsequently  Kussmaul  and  Tenner  *  repeated 
these  experiments  in  a  much  more  perfect  manner  up- 
on dogs,  cats,  and  rabbits,  and  succeeded  in  conclu- 
sively demonstrating  that  rapid  and  profuse  haemor- 
rhage is  followed  by  violent  and  general  convulsions. 
"  If,"  however,  "  haemorrhage  takes  place  slowly,  and 
the  vital  powers  are   gradually    consumed,  death    ap- 


*Moleschott's  "  Untersuchungen,"  Band  ii,  p.  248,  1857. 
Also  "Epileptiform  Convulsions  caused  by  Profuse  Bleeding," 
etc..  by  Adolf  Kussmaul  and  Adolf  Tenner.  The  New  Syden- 
ham Society,  London,  1859. 


pears  then  to  ensue  with  swooning,  drowsiness,  de- 
lirium, and  vascular  irritation  without  convulsions." 

"  More  than  twenty  rabbits,  which  we  either 
killed  intentionally  by  rapid  bleeding,  or  which  ex- 
pired while  being  experimented  upon,  died  under 
general  convulsions  like  those  observed  in  epilepsy, 
and  which  we  shall  afterward  more  fully  describe. 
Not  one  of  those  which  we  saw  die  bleeding  was  ex- 
empt from  convulsions.  These  convulsions  did  not 
differ  in  any  respect  from  those  we  observed  in  several 
dogs  and  cats  that  died  from  bleeding,  or  from  those 
described  as  occurring  in  men  dying  from  haemor- 
rhage."* 

Kussmaul  and  Tenner  have  also  shown  that  an 
interruption  in  the  conveyance  of  arterial  blood  to  the 
brain  of  a  rabbit  produces  epileptic  fits  with  as  much 
certainty  as  general  haemorrhage.  Referring  to  the 
point,  they  state  that  "  no  difference,  moreover,  could 
be  discerned  between  the  fits  observed  in  death  from 
bleeding  and  those  which  occurred  in  about  one  hun- 
dred rabbits  whose  carotid  and  subclavian  arteries 
were  tied  or  compressed  below  the  origin  of  the 
vertebral  arteries." 

And  again:  "Lastly,  we  become  convinced,  by 
observation  of  more  than  a  dozen  rabbits,  that  the  fits 
produced  by  compression  of  the  above-mentioned 
arteries  resemble  in  every  way  those  brought  on  acci- 


*  Op.  cit.,  p,  2,  foot-note. 


dentally  or  intentionally  in  the  identical  *  animals  by 
profuse  haemorrhage  after  circulation  has  been  re- 
stored to  the  head." 


*  The  Italics  are  ours. 


CHAPTER  VIII. 

EXPERIMENTAL  RESEARCHES  CONTINUED. 

I  can  not  refrain  from  giving  a  description  of  the 
convulsive  paroxysms  induced  in  rabbits  after  ligature 
of  the  great  arteries  of  the  neck,  in  the  eloquent 
language  of  Kussmaul  and  Tenner.  The  quotation  is 
made  from  the  paper  already  referred  to: 

"  General  convulsions  usually  followed  in  from  eight  to 
eighteen  seconds  after  complete  withdrawal  of  arterial  blood. 
We  killed  six  rabbits  solely  for  the  purpose  of  determining  in 
what  space  of  time  convulsions  would  come  on.  After  the 
arteries  had  been  laid  bare,  and  the  ligatures  had  been  passed 
lound,  we  allowed  the  animals  to  rest  undisturbed  in  an  erect 
position  for  a  quarter  of  an  hour,  without  making  any  experi- 
ments by  compression.  One  of  us  then  as  quickly  as  possible, 
tied  the  left  subclavian  and  innominate  arteries,  while  another, 
watch  in  hand,  observed  the  time  when  the  symptoms  first 
manifested  themselves. 

"  In  a  very  strong  male  rabbit,  two  years  old,  general  con- 
vulsions came  on  three  seconds  after  the  innominate  had  been 
tied :  and  this  is  the  shortest  period  that  we  have  noticed  in 
any.  In  two  female  white  rabbits,  four  weeks  old,  the  convul- 
sions appeared  after  an  interval  of  twelve  seconds;  in  a  female 
gray  rabbit,  two  or  three  years  old,  in  ten  seconds;  in  a  male 
of  the  same  age,  in  sixteen  seconds;  and  in  an  old  strong  fe- 
male, from  four  to  five  years  old,  in  forty-five  seconds.  None 
of  these  animals  lost  during  the  operations  any  considerable 
quantity  of  blood. 

"  Out  of  a  hundred  strong  rabbits,  we  met  with  four  only 


124    — 

in  which,  after  perfect  closure  of  the  above-named  vessels,  con- 
vulsions did  not  appear  till  after  four  to  six  minutes,  and  one 
only,  as  already  mentioned,  in  which  they  did  not  appear  at  all 
after  the  lapse  of  ten  minutes,  and  until  the  aorta  had  been 
opened." 

The  occurrence  of  convulsions  is  always  preceded 
by  various  motor  phenomena,  which  have  been  ex- 
haustively described  by  KussmauL*  The  most  im- 
portant of  these  are  as  follows: 

1.  "  Immediately  after  stoppage  of  the  blood  the 
various  sphincter  muscles  of  the  face  contract,  especi- 
ally, and  in  a  very  striking  manner,  those  of  the  iris 
and  eyelids;  then,  in  the  order  of  their  distinctness, 
the  conchse  of  the  ears,  the  nostrils,  and  the  mouth. 
The  jaws,  which  are  generally  already  closed,  become 
spasmodically  locked.  Then,  usually  a  little  before, 
but  sometimes  simultaneously  upon  the  occurrence  of 
general  convulsions,  the  pupils  and  the  fissures  of  the 
eyelids,  ears,  and  nostrils  are  widened,  sometimes  the 
mouth  also,  very  distinctly.  The  adductors  of  the 
lower  jaw  seem  also  for  a  few  moments  to  become 
paralyzed;  but  during  the  attack  the  jaw  becomes 
locked,  either  uninterruptedly  or  in  broken  succession, 
by  the  alternate  occurrence  of  spasmodic  and  more 
feeble  abductions  and  stronger  adductiofis ." 

2.  ''  Convulsive  efforts  are  almost  invariably 
made  to  turn  the  pupils  toward   the  internal  angles 


*  Vide  article  by  Adolf  Kussmaul   in    "  Zeitschrift   des 
Wurtzburg.  phys.  med.  Vereins." 


—    125    — 

of  the  eyes,  after  which  the  eyeballs  generally  roll 
about,  first  inward,  forward,  and  downward,  then  out- 
ward, backward,  and  upward,  until  at  length  the 
pupils  are  turned  toward  the  external  angles  of  the 
eyes,  and  are  wholly  or  partially  concealed  by  the 
upper  eyelids." 

3.  "  The  eyeballs  are  first  drawn  back  into  the 
sockets,  and  again  become  prominent  as  the  pupils  di- 
late." 

4.  "  Respiration  is  at  first  accelerated,  but  short- 
ly afterward,  a  little  while  before  the  approach  of 
the  general  convulsions,  it  becomes  prolonged  and 
deep." 

5.  "  The  muscles  of  the  neck  generally  become 
paralyzed  and  unable  to  bear  the  weight  of  the  head, 
which  sinks  down  upon  the  breast  or  side,  the  ani- 
mals afterward  falling  down  in  a  swoon  on  their  fore 
feet,  occasionally  on  their  hind  ones.  The  symptoms 
of  paralysis  are  the  more  distinct  and  constant  the 
greater  the  time  that  elapses  before  general  convul- 
sions come  on." 

"  The  signal  for  general  convulsions  is  given  by  a 
tonic  contraction  of  the  muscles  of  the  neck.  Then 
commences  a  terrible  scene,  the  more  surprising  by 
contrast  if  preceded  by  swooning.  The  head  is  drawn 
violently  backward,  the  pupil  becomes  uncommonly 
enlarged,  violent  lock-jaw  ensues,  and  the  animal,  if 
strong,  is  generally  flung  forward  with  great  force  to 
a  distance  even  of  from  one  to  two  feet,   and  some- 


126     

times  over  the  shoulders  of  the  observer  seated  before 
it.  The  legs  are  alternately  contracted  and  extended 
by  clonic  convulsions  in  the  most  violent  way;  the  en- 
larged pupil  appears  again  fixed  in  the  centre  of  the 
palpebral  fissure,  as  the  eyeball  is  again  rolled  some- 
what inward;  respiration  is  scarcely  to  be  perceived, 
while  the  heart  continues  throbbing  very  vigorously. 
The  clonic  convulsions  gradually  subside,  assuming 
more  the  appearance  of  tetanus,  and  eventually  disap- 
pear altogether,  passing  away  as  they  do  so  from  the 
front  to  the  back.  First,  the  muscles  of  the  neck  and 
fore  legs  become  paralyzed,  while  the  back  part  of  the 
body  is  bent  forward  and  the  hind  legs  are  tetanically 
extended  until  these  movements  also  cease.  The 
duration  of  these  attacks  was,  according  to  several  ob- 
servations, from  eighteen  seconds  to  two  minutes. 

"  Very  frequently,  after  a  pause  of  from  fifteen  to 
seventy-five  seconds,  a  second  attack  comes  on,  always 
weaker  and  shorter  than  the  first,  and  often  limited  to 
the  hinder  part  of  the  body,  in  the  form  of  tetanic 
convulsions;  sometimes,  however,  affecting,  the  whole 
body,  under  the  form  of  clonic  convulsions.  We  once 
observed  such  a  second  attack  to  last,  in  an  exception- 
al case,  two  minutes.  Sometimes,  indeed,  convulsions, 
in  which  the  hind  legs  become  tetanically  stretched, 
recur  even  for  a  third  and  fourth  time,  at  intervals  of 
from  fifteen  to  thirty  seconds.  They  returned  in 
the  strongest  and  most  regular  manner  in  those 
animals  whose  arteries  were  tied  forthwith,  and  whose 


127    — 

strength  had  not  been  previously  exhausted  by  experi- 
ments of  compression.  Toward  the  end  of  the  attacks, 
urine  and  faeces  were  sometimes  voided;  at  other 
times  no  such  voiding  took  place,  even  when  the 
bladder  was  full. 

"  In  rabbits,  cats,  and  dogs,  dying  from  haemor- 
rhage, the  convulsions  are  of  exactly  the  same  char- 
acter. 

"These  convulsions  present  precisely  similar 
features  to  those  of  epilepsy  in  their  complete  form,  as 
the  following  enumeration  of  the  most  important 
symptoms  will  show: 

1.  "  The  animals  fall  down  before  general  con- 
vulsions come  on,  and  completely  lose  the  spontaneous 
use  of  their  muscles." 

2.  "  They  give  the  observer  the  impression  of 
their  being  perfectly  unconscious." 

3.  "  Not  one  of  the  many  animals  operated  upon 
cried  out,  so  long  as  the  circulation  was  interrupted, 
either  before  or  during  the  spasmodic  attack,  and  two 
only  while  the  latter  was  abating.  Subsequently, 
however,  they  began  to  cry  piteously  directly  arterial 
blood  began  to  flow  again,  or,  at  all  events,  soon  after- 
ward. From  the  want  of  power  to  cry,  and  from  the 
gradual  swelling  of  the  veins  of  the  brain  during  the 
attack,  to  which  we  shall  direct  attention  further  on, 
we  infer  that  spasm  of  the  glottis  (laryngismus)  took 
place." 

4.  "  The  pupils  are   dilated  during  the  attacks, 


—     128    — 

and,  to  judge  from  several  experiments,  appear  rigid, 
the  eyeballs  bemg  motionless.  Before  and  subsequent 
to  the  attacks,  however,  and  when  •  at  the  very  last 
gasp,  the  pupils  being  at  the  same  time  very  much  en- 
larged, the  eyes  of  some  animals  that  were  accurately 
examined  appeared  sensible  to  the  influence  of  light." 

5.  "  The  attacks  commence  with  a  toxic  spasm 
of  the  neck  (trachelismus.)" 

6.  "  Respiration  ceases,  while  the  heart  con- 
tinues beating." 

7.  "  The  limbs  are  seized  with  strong  clonic  con- 
vulsions, and  become  at  last  spasmodically  stretched." 

Besides  the  experiments  above  referred  to,  Kuss- 
maul  and  Tenner  inaugurated  a  series  of  researches 
which  had  for  their  object  the  more  precise  localiza- 
tion of  the  cerebral  regions  from  whence  general  con- 
vulsions arise.* 

The  modus  operandi  in  these  researches  was  as  fol- 
lows: Various  districts  of  the  brain  were  cut  out,  and 
a  comparison  of  the  effects  produced  by  compressing 
the  great  arteries  of  the  head  before  and  after  the 
operation  was  instituted.  In  this  manner  the  follow- 
ing conclusions  were  arrived  at:  That  anaemia  of 
those  parts  of  the  brain  situated  in  front  of  the  crura 


*On  the  Mode  of  Procedure  for  Determining  the  Cerebral 
Region  from  whence  General  Convulsions  after  Profuse 
Haemorrhage  Arise,"  by  Adolf  KussmuU  and  Adolf  Tenner. 
"The  New  Sydenham  Soc,"  1859,  vol.  v,  p.  to  et  seq. 


129    — 

cerebri  produces  unconscioueness,  insensibility,  and 
paralysis,  if  spasms  occur  with  these  symptoms,  some 
excitable  parts  behind  the  thalami  optici  must  have 
likewise  undergone  some  change.* 

This  portion  of  their  experiments  is,  however, 
open  to  criticism,  since  the  sources  of  error  are  numer- 
ous. Among  the  latter,  I  will  only  mention  the  com- 
plications liable  to  arise  from  opening  the  skull — a 
procedure  inevitably  accompanied  by  changes  in  pres- 
sure, and,  in  this  case,  by  escape  of  the  cerebro-spinal 
fluid,  and  no  little  hsemorrhage. 

I  shall  take  occasion  to  refer  at  length  to  the 
further  conclusions  arrived  at  by  Kussmaul  and 
Tenner  relative  to  the  pathology  of  epilepsy  in  the 
subsequent  paragraph  on  the  mechanism  of  the 
epileptic  seizure. 

Landois  has  conducted  some  interesting  experi- 
ments, which  show  the  relation  of  venous  hyperemia 
of  the  brain  and  superior  portion  of  the  spinal  cord  to 
epileptoid  convulsions,  f 

The  mode  of  procedure  in  these  researches  was 
as  follows:  The  right  thoracic  cavity  was  opened  and 
the  superior  vena  cava  exposed   in   such   wise  that  it 


*  Vide  under  head  of  General  Summary,  op.  cit.,   p.    105. 

f "  Ueber  den  Einfluss  der  venosen  Hyperamie  des 
Gehirns  und  des  verlangerten  Markes  auf  die  Herzbewegung, 
nebst  Bemerkungen  liber  die  fallsuchtartigen  Anfalle,"von  Dr. 
Leonard  Landois.  "  Centralblatt  fur  die  medicinischen  Wis- 
senschaften,"  p.  146,  1867. 


was  possible  to  close  the  lumen  of  the  same  by  means 
of  an  ordinary  artery  forceps.  Artificial  respiration 
was  instituted,  in  order  to  neutralize  as  far  as  possible 
the  respiratory  derangements  unavoidably  arising  from 
opening  one  side  or  the  thorax. 

Among  other  phenomena,  Landois  observed,  after 
closure  of  the  superior  vena  cava  (in  the  rabbit):  i. 
Retardation  of  the  heart's  action;  and,  2,  "Complete 
epileptoid  seizures." 

The  latter  observation  is  one  of  great  importance 
from  a  pathogenic  point  of  view,  since  we  are  thus 
made  aware  not  only  that  cerebral  anaemia  is  capable 
of  producing  epileptoid  convulsions  (as  shown  by 
Kussmaul  and  Tenner),  but  that  profound  venous 
hypersemia  of  the  central  nervous  system  is  equally 
provocative  of  the  same  phenomena.*  We  can  readily 
understand,  moreover,  why  the  convulsions  are  per- 
petuated during  the  second  stage  of  the  epileptic 
attack — that  period  of  the  seizure  when  the  brain  is 
evidently  in  a  state  of  profound  venous  engorgement. 

In  1868,  Dr.  H.  Nothnagelf  drew  attention  .  to 
the  fact  that,  although  it  had  long  been  known  that 
irritation  of  the  floor  of  the  fourth  ventricle  gave  rise  to 
irregular  general  convulsions,   no  attempt  had  been 


*  "  Die  Entstehung  allgemeiner  Convulsionen  von  Pons 
und  von  der  Medulla  oblongata  aus,"  von  Dr.  D.  Nothnagel. 
"Archiv.  fiir  pathologische  Anatomie  und  Physiologie  und  fUr 
klinische  Medicin,"  Bd.  xliv,  p.  i,  1868. 

f  Op.  cic,  pp.  146  and  147. 


—  131  — 
made  to  locate  the  district  in  question  with  greater  pre- 
cision. That  more  exact  researches  in  this  regard 
were  really  necessary  was  proved  by  the  fact  that  ex- 
periments, undertaken  in  the  light  of  the  popular  con- 
ception with  regard  to  the  '•convulsive"  functions  of 
the  floor  of  the  fourth  verticle,  frequently  failed  to 
produce  any  spasmodic  phenomena  whatsoever. 

Accordingly,  Nothnagel  instituted  a  series  of  ex- 
periments with  a  view  to  determining  with  greater 
precision  the  locality  in  the  medulla  whose  irritation  is 
followed  by  general  convulsions. 

The  technique  of  these  experiments  was  extremely 
simple.  The  animal  was  placed  upon  the  abdomen 
and  secured  with  appropriate  appliances.  The  soft 
parts  were  then  divided  so  as  to  expose  the  occipital 
portion  of  the  head  between  the  crista  and  protuber- 
antia  occipitalis.  Then  the  skull  was  pierced  by 
means  of  a  strong  needle  (care  being  taked  to  avoid 
the  openings  for  the  vasa  emissaria  Santorini).  Finally, 
penetration  of  the  organs  within  was  effected  by  means 
of  a  fine  needle.  This  procedure  was  followed  by 
compulsory  movements,  general  epileptoid  convulsions, 
or  the  animal  remained  perfectly  quiet,  according  to 
the  part  penetrated.  Confirmatory  evidence  was  sub- 
sequently afforded  by  post-mortem  examination. 

In  this  simple  manner  Nothnagel  was  able  to  de- 
termine with  great  exactness  the  boundaries  of  what 
he  has  expressively  termed  the  "convulsion  center" 
{Krampfbezirk).     The   lower  limit  of  this  district  is 


—    132    — 

situated  at  the  upper  portion  of  the  alcz  cineretz;  the 
upper  limit  lies  somewhat  above  the  locus  cceruleus; 
the  inner  limit  is  constituted  by  the  outer  lateral  border 
of  the  eminenticz  teretesj  the  outer  limit  is  more  difficult 
to  locate,  but  the  upper  boundary  line  appears  to  be 
formed  by  the  locus  cceruleus,  whereas,  below  it  corre- 
sponds to  the  inner  border  of  the  tuberculum  acusti- 
cum.^ 

The  depth  of  the  district  is  very  difficult  to  deter- 
mine, as  the  slightest  movement  on  the  part  of  the 
hand  of  the  operator  causes  the  needle  to  penetrate 
unduly  the  yielding  nervous  tissue.  When  the  needle 
penetrates  the  above  mentioned  district  (the  "convul- 
sion center"),  the  following  phenomena  are  observed: 

"At  the  moment  of  penetration  severe  opisthot- 
onus and  tetanic  extension  of  the  spinal  column  take 
place.  Although  firmly  secured,  the  animal  makes 
spasmodic  movements  with  the  extremities.  When 
released  it  presents  the  spectacle  of  the  most  pro- 
nounced epileptoid  convulsions.  The  extremities  are 
the  seat  of  violent  irregular  contractions,  the  posterior 
being  sometimes  more  affected  than  the  anterior  limbs. 
At  the  same  time  the  entire  animal  is  thrown  from 
side  to  side.  ...  In  from  one-half  to  three  minutes 
the  violence  of  the  paroxysms  subsides,  and  the  ani- 
mal remains  quiet,  but  the  extremities  still  continue 
extended  and  the  spinal  column  is  perfectly  rigid."  A 

*  Op.  cit.,  p.  5. 


—  ^33  — 

blow  upon  the  table  is  sufficient  to  again  evoke  the 
convulsions,  but  the  latter  sometimes  break  forth  anew 
spontaneously. 

From  these  experiments,  Nothnagel  concludes 
that  the  central  point  of  departure  of  general  convul- 
sions is  to  be  sought  for  in  the  pons.  The  lower  limit 
of  that  portion  of  the  central  nervous  system  which  is 
the  point  of  departure  of  general  epileptiform  convul- 
sions is  represented  by  a  transverse  section  situated  at 
the  lower  boundary  of  the  pons.* 

These,  then,  are  the  experiments  upon  which 
Nothnagel  has  founded  his  theory  of  epilepsy.  I  shall 
take  occasion  to  again  refer  to  the  latter  in  the  subse- 
quent paragraph  on  the  nature  of  the  paroxysm. 

In  1850  Dr.  JBrown-Sequard  f  succeeded  in  de- 
monstrating that  certain  lesions  of  the  spinal  cord  in 
mammals  are  followed  in  a  few  weeks  by  convulsions 
bearing  a  strong  resemblance  to  those  of  epilepsy. 
After  a  long  series  of  experiments  on  guinea-pigs,  he 
found,  moreover,  that  all  the  lesions  of  the  cord 
enumerated  below  are  capable  of  evoking  these  con- 
vulsive phenomena: 

I.  Complete  or  almost  complete  transverse  sec- 
tion of  one  lateral  half  of  the  cord 


*  Op.  cit.,  p.  9. 

f  Vide  "Comptes  rendus  de  la  Societe  de  biologic,"  1850, 
vol.  ii;  "Archives  generales  de  medecine,"  1856,  vol.  i  (v.  serie, 
tome  7),  p.  143;  "Lancet,"  1861;  "Bull,  de  1' Academic  de 
med.  de  Paris,"  Jan.,  mals,"  etc.,  1857. 


—  134  — 

2.  Simultaneous  transverse  section  of  the  poste- 
rior columnSjOf  the  posterior  horns  of  gray  matter,  and 
of  a  portion  of  the  lateral  columns. 

3.  Transverse  section  of  the  posterior  columns, 
or  of  the  lateral  columns,  or  of  the  anterior  columns 
alone. 

4.  Complete  transverse  section  of  the  cord. 

5.  Simple  puncture  of  the  cord. 

Of  these  lesions,  the  first  two  are  apparently  those 
which  are  most  liable  to  develop  the  convulsive  condi- 
tion. 

That  portion  of  the  cord  situated  between  the 
seventh  or  eighth  dorsal  and  the  third  lumbar  verte- 
brae is  most  susceptible  to  wounds.  Lesions  of  this 
region  are  particularly  prone  to  develope  the  convul- 
sive condition. 

In  the  majority  of  cases,  the  convulsive  symptoms 
appear  during  the  third  week  subsequeut  to  the  lesion. 

Sometimes  the  convulsions  appear  without  the 
aid  of  extraneous  excitation.  As  a  rule,  however, 
they  are  readily  evoked  by  irritation  of  certain  circum- 
scribed portions  of  the  integument.  That  portion  of 
the  body  the  irritation  of  which  causes  convulsions 
has  been  termed  by  Brown-Sequard  the  ^''  epileptogenous 
zone'' 

This  author  has  also  shown  that  section  of  the 
more  important  nerve-trunks,  such  as  the  internal 
popliteal  and  sciatic,  and  also  lesions  of  the  crura  cere- 


—   '35  — 
bri  or  corpora  quadrigemina,  are  particularly  prone  to 
develop  the  epileptic  condition.* 

The  offspring  of  animals  affected  by  epilepsy 
caused  by  lesions  of  the  nervous  system  may  develop 
the  epileptic  condition,  as  Dr.  Brown-Sequard  has 
conclusively  demonstrated. 

A  suggestive  circumstance  in  connection  with  the 
epileptogenous  zone  is  the  fact  that  the  latter  is  always 
situated  on  the  same  side  as  the  lesion  of  the  spinal 
cord  or  nerve;  but,  when  the  crus  cerebri  is  injured, 
it  is  found  on  the  opposite  side  of  the  lesion. 

Westphal,f  while  endeavoring  to  determine 
whether  the  epileptoid  convulsions  previously  de- 
scribed by  Brown-Sequard  might  be  determined  by 
certain  injuries  to  the  skin,  discovered  the  interesting 
fact  that,  when  a  guinea-pig  receives  a  blow,  or  a 
series  of  blows  upon  the  head,  the  animal  is  at  once 
seized  with  a  violent  convulsive  attack.  The  convul- 
sions thus  induced  resemble  in  every  respect  those 
produced  by  Brown-Sequard  in  the  same  animal  by 
injuries  to  the  nerves  or  spinal  cord.  The  seizure 
takes  place  immediately  after  the  blow,  or  after  the 
lapse  of  a  few  minutes.  When  the  convulsions  have 
subsided,  the  animal  appears  to  recover  its  normal 
condition;   and  attempts   to  cause    a  renewal    of  the 


*  "  Researches  on  Epilepsy,"  etc.,  by  Brown-Sequard, 
1857.     Also  articles  in  journals  already  referred  to. 

f  "  Ueber  kiinstliche  Erzeugung  von  Epilepsie  bie  Meer- 
schweinchen,"  Berliner  klinische  Wochenschrift,  No.  38,   1871. 


—  136  — 

seizure  by  irritating  that  portion  of  the  skin  which 
Brown-Sequard  has  called  the  "  epileptogenous  zone  " 
are  without  avail.  A  different  state  of  things  is,  how- 
ever, observed  to  exist  after  the  lapse  of  a  few  weeks; 
for,  if  now  the  animal  is  irritated  by  pinching,  par- 
ticularly in  the  neighborhood  of  the  lower  jaw,  an  at- 
tack of  convulsions  is  immediately  produced. 

The  susceptibility  to  a  convulsive  condition 
evoked  by  blows  is  hereditary,  like  the  corresponding 
state  which  Brown-Sequard  succeeded  in  establishing 
by  means  of  injuries  to  the  spinal  cord  and  nerve- 
trunks. f 

Dr.  V.  Magnan  J  and  M.  Challand  §  have  shown 
in  animals  that  absinthe,  when  introduced  into  the 
system,  produces  convulsions  of  an  epileptoid  char- 
acter. The  following  experiment,  performed  by  Dr. 
Magnan  on  a  dog,  is  most  interesting,  as  showing  the 
possibility  of  producing  hallucinations  as  well  as 
epileptic  attacks  by  the  administration  of  absinthe: 
"  In  a  dog  weighing  thirty-one  pounds,  into  whose 
stomach  we  injected  five  grammes  (about  seventy-five 
minims)  of  essence  of  absinthe  at  9:15   a.  m.,  we  ob- 


t  Op.  dtp.  45  r. 

I  "On  Alcoholism,  the  Various  Forms  of  Alcoholic 
Delirium  and  their  Treatment,"  by  Dr.  V.  Magnan,  London, 
1876,  p.  26. 

§  Challand.  "'  Experiments  made  at  the  Hotel  Dieu  at 
Professor  Behier's  Clinique,"  cited  by  Dr.  Magnan  in  his 
monograph  on  "  Alcoholism,"  p.  26  et  seq. 


—  137  — 

served  a  first  attack  of  epilepsy  at  9:45  a.  m.;  ten 
minutes  later  a  second  attack  occurs,  followed  by  a 
slight  degree  of  stupor;  quickly  becoming  himself 
again,  the  animal  continues  playful,  answers  a  call, 
walks  and  runs  easily.  Quite  suddenly,  and  without 
any  provocation,  he  raises  himself  on  his  feet,  with 
hair  bristling,  angry  look,  eyes  injected  and  brilliant; 
he  fixes  his  gaze  on  a  wall  which  is  completely  bare, 
and  on  which  there  is  nothing  to  draw  his  attention; 
bending  down  with  the  paws  forward  and  the  neck 
stretched  ready  to  spring,  he  advances  and  recoils 
alternately,  barks  furiously,  and  gives  himself  up  to  a 
furious  battle;  clashing  his  jaws,  and  making  sudden 
movements  as  if  to  seize  an  enemy,  he  shakes  his  head 
from  side  to  side,  clinching  his  teeth  as  if  to  tear  his 
prey.  By  degrees  he  becomes  calm,  but  still  looks 
several  times  in  the  same  direction,  growling,  and  then 
regains  confidence  completely." 

Finally,  it  is  worthy  of  note  that  both  Ferrier  and 
Bartholow  have  succeeded  in  evoking  epileptoid 
convulsions  by  the  direct  application  of  the  faradaic 
current  to  the  brain.  Convulsions  have  also  been 
caused  by  injury  to  the  cortical  motor  areas. f  In  all 
experiments  of  this  nature,  in  which  electricity  is  em- 
ployed for  the  purpose  of  exciting  the  nervous  sub- 


*  Op.  et  loc.  cit. 

f  "  Untersuchungen   tiber  das  Gehirn,"  1864,  and  other 
writings  of  Hitzig. 


-  138  - 

stance,  it  should  be  borne  in  mind  that  the  localiza- 
tion of  the  current  is  a  matter  of  so  much  difficulty 
that  great  caution  should  be  exercised  in  drawing  con- 
clusions as  to  the  relative  functional  importance  of 
neighboring  districts. 

Having  thus  reviewed  in  succession  those  experi- 
mental researches  which  are  best  calculated  to  shed 
light  upon  the  intricate  questions  of  pathology  in- 
volved, it  now  remains  to  discuss  the  mechanism  of 
the  attack  itself — a  task  which  will  be  greatly  facili- 
tated by  the  preliminary  knowledge  at  our  disposal 


CHAPTER  IX. 

PATHO-ANATOMICAL  FINDINGS. 

So  various  have  been  the  changes  recorded  by 
pathologists  in  epilepsy  that,  if  an  attempt  were  made 
to  construct  an  explanation  of  the  seizure  upon  such  a 
basis,  it  would  be  found  to  resemble  in  intricacy  a 
veritable  Gordian  knot.  There  is,  in  truth,  hardly  an 
organ  in  the  entire  body  which  has  not  been  found 
diseased  in  this  affection.  Ignoring  the  morbid 
changes  in  the  viscera,  which  are  evidently  of  colla- 
teral importance,  it  will  be  well  for  the  completeness 
of  the  argument  to  bestow  a  glance  upon  the  more 
striking  appearances  found  in  the  brain,  medulla,  and 
the  remaining  portions  of  the  cord,  and  their  appen- 
dices. 

First  of  all,  then,  it  has  been  affirmed  that  the 
weight  of  the  brain  is  increased  in  epilepsy;*  but,  on 
the  other  hand,  equally  positive  statements  are  at  hand 
which  go  to  show  that,  in  some  cases  at  least,  the 
weight  of  the  organ  is  decreased. f 

Unequal  proportions  of  the  two  hemispheres  has 
also  been  alleged,  but  is  certainly  by  no  hieans  so  fre- 
quently met  with  as  was  formerly  supposed. 

Meynert  and  others  have  found   sclerosis  of  the 


*  Echeverria,  "On  Epilepsy,"  New  York,  1870. 

f  Meynert,    "  Vierteljahrasschrift  fiir  Psychiatric,"  1867. 


—  140  — 

cornu  Ammonis,  but  I  believe  he  rightly  considers  this 
change  of  secondary  origin  only.  But  I  would  go  a 
step  further  and  maintain  that  the  lesion  in  question 
can  not  possess  the  slightest  importance  whatever,  so 
far  as  the  development  of  the  paroxysm  is  concerned, 
since,  when  this  portion  of  the  brain  is  removed,  con- 
vulsive phenomena  are  neither  evoked  nor  increased 
when  they  already  exist. 

Without  entering  upon  a  recapitulation  of  the 
various  tumors  which  have  been  found  associated 
with  epileptic  phenomena,  I  will  content  myself  with 
enumerating  some  of  the  further  and  more  obvious 
changes  about  the  cord  and  brain  which  have  been 
noted  within  the  last  few  years:  (i)  atheroma  and 
aneurism  of  blood-vessels;  (2)  dilatation  of  the  vessels 
of  the  superior  portion  of  the  cord;  (3)  temporary  or 
permanent  anaemia  of  the  brain,  resulting  from  general 
causes  or  from  local  vaso-motor  insufficiency;  (4)  in- 
crease in  quantity  of  the  cerebro-spinal  fluid;  (5)  thick- 
ening of  the  meninges  of  the  brain. 

Of  these  changes,  the  latter  must  be  regarded  as 
of  most  importance,  since  it  is  found  in  a  considerable 
number  of  cases.  But,  though  cortical  function  is  in- 
terfered with  in  all  true  cases  of  epilepsy,  it  would  be 
a  decided  mistake  to  ascribe  such  alterations  to  men- 
ingeal changes,  since  in  a  by  no  means  insignificant 
number  of  cases  neither  they  nor  indeed  any  other 
morbid  appearances  are  discernible,  even  upon  the 
closest    and    most    improved    methods    of    scrutiny. 


—   141   — 

There  is  consequently  no  question  in  my  own  mind 
that,  where  these  evidences  of  meningitis  do  occur, 
they  are,  like  most  of  the  other  changes  recorded,  to 
be  regarded  as  of  purely  secondary  origin — to  be  ac- 
counted for,  perhaps,  by  the  violent  circulator}"  fluctua- 
tions which  are  so  characteristic  of  the  disease. 

Still,  when  once  established,  these  thickened 
membranes  have  an  undoubted  influence  upon  the 
prognosis.  Thus,  in  three  cases  of  severe  epilepsy, 
with  psychical  complications,  in  which  I  have  made 
post-mortem  examinations,  these  thickened  and  ad- 
herent members  were  a  prominent  feature.  In  such 
cases  there  is,  I  believe,  little  or  no  chance  of  either 
recovery  or  benefit,  since  the  derangements  in  cortical 
nutrition  caused  by  such  lesions  must  of  necessity  be 
profound  in  character,  and  practically  irremediable. 


CHAPTER  X. 

THE  MECHANISM  OF  THE  EPILEPTIC  SEIZURE. 

Enough  has  already  been  said  concerning  the 
various  morbid  anatomical  findings  in  epilepsy  to 
prove  conclusively  that  there  is  absolutely  nothing 
either  characteristic  or  constant  in  their  occurrence. 
Consequently,  if  epilepsy  is  to  be  regarded  as  a 
malady /(?r  se,  and  not  as  a  mere  symptom  of  multi- 
tudinous forms  of  central  nervous  disease,  we  must 
look  elsewhere  for  an  adequate  explanation  of  the 
true  nature  of  the  affection.  Undoubtedly  the  most 
consistent  theory  of  the  disease  is  based  upon  con- 
siderations derived  from  experimental  physiology  and 
pathology. 

Without  anticipating  further,  however,  it  will  be 
well  to  review  briefly  the  more  prominent  hypotheses 
relative  to  the  nature  of  the  disease  which  have  been 
advanced  by  various  writers  on  the  subject  from  time 
to  time. 

According  to  Marshall  Hall,*  the  mechanism  of 

*  The  following  are  the  principal  writings  in  which  Mar- 
shall Hall  has  embodied  his  views  relative  to  the  pathology  of 
epilepsy:  "  Essays  on  the  Theory  of  Convulsive  Diseases  and 
Derangements  of  the  Nervous  System;"  "Synopsis  of  Cerebral 
and  Spinal  Seizures  of  Inorganic  Origin  and  of  Paroxysmal 
Form;"  "  Synopsis  of  Apoplexy  arid  Epilepsy,  with  Observa- 
tions on  Trachelismus,  Laryngismus,  and, Tracheotomy,"  1852; 
"  On  the  Neck  as  a  Medical  Region,"  "  Lancet,"  1849;  "Me- 
moirs on  the  Nervous  System,"  London,  1837. 


—  143  — 
the  seizure  may  be  formulated  somewhat  as  follows: 
(i)  excitation  of  a  sensory  nerve  or  direct  central  ex- 
citation, which  gives  rise  in  the   first  place   to  reflex 
spasm  of  the  muscles  of  the  neck,  causing  compression 
of  the  cervical  veins  with  consequent  comatose  symp- 
toms; and,  secondly,  to  a  reflex  tonic  spasm  of  the 
muscles  of  the  larynx,  closing  of  the  rima  glottidis 
(laryngismus),  causing  asphyxia  with  consequent  con- 
vulsions      In    other  words,  the  condition   of  uncon- 
sciousness is  ascribed  to  venous  engorgement,  and  the 
convulsions  to  general  asphyxia. 

Plausibility  was  lent  to  that  portion  of  the  theory 
which  assumes  contraction  of  the  muscles  of  the  neck 
as  the  cause  of  the  venous  stasis  by  the   experiments 
of  Reynolds       This  observer  found  that  contraction 
of  the  cervical  muscles  actually  did  produce  stasis  of 
the  veins  of  the  neck,  with  concomitant  cerebral   dis- 
turbances.     But,   on  the  other  hand,   Kussmaul  and 
Tenner*  have  shown,  by  conclusive  experiments,  that 
occlusion  of  the  larynx  is  capable  of  producing  both 
coma  and  convulsions.    As  a  consequence,  they  refuse 
to  accept  the  first  portion  of  Hall's  theory.    It  may  be 
well  to  add  in  this  connection  that  both  of  these  ob- 
servers guided  by  clinical  and  experimental  data,  ar- 
rived  at  the  conclusion  that  the  phenomena  of  the 
affection,  and  particularly  the  unconsciousness,  could 

^^^^"^the  Nature  and  Origin  of  Epileptiform  Convulsions 
caused  by  Profuse  Bleeding."  by  A.  Kussmaul  and  A.  Tenner. 
"New  Sydenham  Society,"  1859. 


—   144  — 

not  be  accounted  for  by  any  merely  local  anatomical 
lesion,  since  the  concomitant  participation  of  the  cere- 
brum was  evidently  a  sine  qua  no7i.  Moreover,  they 
conclude  that  it  is  not  necessary  to  assume  a  constant 
or  gross  change  appreciable  by  the  pathological  ana- 
tomist, but  that  a  pervasive  functional  change  of  tran- 
sient duration  is  sufficient  to  account  for  the  pheno- 
mena of  the  ordinary  epileptic  seizure.  Such  a  per- 
vasive, transitory  change  they  perceive  in  cerebral 
anaemia — a  condition  which,  as  is  well  known,  consti- 
tutes a  prominent  feature  of  the  first  portion  of  the 
epileptic  attack.  Besides  this  clinical  fact,  they  ad- 
duce the  evidence  afforded  by  their  own  experimental 
researches,  to  which  extended  reference  has  already 
been  made,  by  which  it  was  conclusively  shown  that, 
when  the  brain  of  an  animal  is  suddenly  deprived  of 
arterial  blood,  either  by  ligation  or  compression  of  the 
four  great  arteries  which  supply  the  brain,  or  by  bleed- 
ing, epileptic  convulsions  and  coma  are  invariably  pro- 
duced."^    These   observers  also  endeavored  to  cause 


*  These  researches,  as  we  have  already  seen,  were,  to  a 
certain  extent,  anticipated  by  Sir  Astley  Cooper  (vide  "  Guy's 
Hospital  Reports,"  vol.  i,  1836),  who  succeeded  in  demonstra- 
ting upon  rabbits  that  ligation  of  both  carotids  and  compres- 
sion of  the  vertebrals  gave  rise  to  convulsions,  suspension  of 
respiration,  and  unconsciousness.  The  experiments  of  Kuss- 
maul  and  Tenner  were,  however,  more  thorough,  and  were 
conducted  upon  cats  and  dogs  as  well  as  rabbits  (vide  Moles- 
choot's  "  UnterVsuchungen,"  1857,  Bd.  ii.  pp.  247,  248  et  seq. ; 
also,  "  Epileptiform  Convulsions  caused  by  Profuse  Bleeding," 
by  Adolf  Kussmaul  and  Adolf  Tenner,  "  The  New  Sydenham 
Society,"  London,  1859). 


—  145  — 
convulsions  by  faradization  of  the  sympathetic  nerves. 
Only  in  one  case,  however,  were  their  efforts  success- 
ful; but,  had  the  interrupted  galvanic  current  been 
employed,  it  is  possible  that  more  uniform  results 
might  have  been  obtained.  These  failures  are,  how- 
ever, not  to  be  accepted  as  absolutely  negative,  or  as 
fatally  damaging  to  the  general  argument  advanced 
by  these  gentlemen,  since  their  experiments  with 
arterial  compression  and  ligation  served  to  show  that 
the  profound  cerebral  anaemia  resulting  therefrom 
invariably  evoked  general  convulsions  and  uncon- 
sciousness. 

But,  while  recognizing  the  important  part  played 
by  cerebral  anaemia  in  the  i7nmediate  production  of  the 
epileptic  attack,  Kussmaul  and  Tenner  do  not  fail  to 
note  that  behind  all  this  there  must  be  an  ultimate 
morbid  state — an  epileptic  "  condition  "  or  an  epileptic 
"  affection "  which  is  responsible  for  the  occurrence 
of  all  the  phenomena  concerned  in  the  produc- 
tion of  the  seizure.  In  speaking  of  this  "  proximate  " 
or  ultimate  cause  of  the  attack  they  proceed  to  state 
"that  the  proximate  cause  of  the  attacks  can  not  be 
one  of  long  duration,  but  an  alteration  merely  of  a 
temporary  kind.  ...  It  must  be  quickly  de- 
veloped to  its  full  fextent,  and  pass  during  the  attack 
through  its  different  phases,  and,  when  the  latter  are 
over,  cease  completely  or  nearly  so.  How  otherwise 
is  it  reconcilable  that,  after  an  attack,  the  patient  so 
frequently,  and  often  for  so  long  a  time,  recovers  the 


—  146  — 

full  use  of  the  action  of  the  brain  ?"  And  again:  "It 
can  be  no  visible  alteration  of  the  brain,  anatomically 
demonstrable,  that  can  act  as  the  proximate  cause  of 
an  epileptic  attack.  .  .  .  Every  physician  of  the 
present  day,  who  is  at  all  judicious,  will  relinquish  the 
hope,  cherished  with  childish  confidence  by  certain 
schools  and  times,  that  pathological  anatomy  is  destined 
to  give  an  explanation  of  the  nature  and  seat  of  epi- 
lepsy, and  he  will  only  expect  that  result  from  the 
progress  of  the  experimental  physiology  of  the  nerves. 
Material  alterations  in  the  brain  and  its  membranous 
and  osseous  coverings  are,  it  is  true,  most  frequently 
found  in  those  who  have  died  from  epilepsy  and 
eclampsia,  and  are  often  enough  recognized  as  the 
cause  during  life.  Often,  however,  in  spite  of  most 
careful  examinations,  no  anatomically  demonstrable 
alterations  are  found  in  the  structure  of  the  brain,  and 
those  which  do  exist  must  be  generally  regarded,  es- 
pecially in  epilepsy,  as  produced  by  interruptions  to 
the  circulation  and  nutrition  during  the  attacks,  par- 
ticularly if  the  latter  have  frequently  been  repeated 
and  for  a  long  time.  Most  of  the  patients  suffering 
from  this  disease  for  years  afford  the  usual  appear- 
ances found  in  chronic  diseases  of  the  brain.  .  .  ." 
But  "  not  one  of  all  the  anatomical  alterations  in  whose 
train  epilepsy  frequently  appears — such  as  cicatrices, 
tubercles,  and  atrophy  of  the  brain,  or  premature 
coalescence  of  the  sutures  of  the  skull,  with  lessening 
of  its  cavity — leads  invariably  to  this  disease." 


—  147  — 

The  "  disposition,"  then,  "  is  nothing  else  but 
that  state  of  the  brain  which  forms  the  basis  from 
which  the  attacks  arise,  and  can  scarcely  be  conceived 
of  otherwise  than  as  a  very  slight  alteration  of  the 
whole  brain,  or  of  a  narrowly  circumscribed  district, 
while  the  alteration  which  is  the  cause  of  the  attacks 
must  always  affect  the  whole  substance  of  the  brain, 
or  at  all  events  the  greatest  part  of  it,  and  that,  more- 
over, in  an  energetic  manner." 

The  following  is  a  general  summary  of  the  more 
important  conclusions  which  Kussmaul  and  Tenner 
derived  from  their  long  series  of  experiments: 

1.  "  The  convulsions  appearing  in  profuse  hem- 
orrhage of  warm-blooded  animals  (including  man)  re- 
semble those  observed  in  epilepsy." 

2.  "When  the  brain  is  suddenly  deprived  of  its 
red  blood,  convulsions  ensue  of  the  same  description 
as  those  occurring  subsequent  to  ligature  of  the  great 
arteries  of  the  neck." 

3.  ''  Epileptic  convulsions  are  likewise  brought 
on  when  the  arterial  blood  rapidly  assumes  a  venous 
character,  as,  for  example,  when  a  ligature  is  applied 
to  the  trachea." 

4.  "  It  is  highly  probable  that  in  these  cases  the 
attack  of  spasms  depends  upon  the  suddenly  inter- 
rupted nutrition  of  the  brain.  It  is  not  caused  by  the 
altered  pressure  which  the  brain  undergoes." 

5.  "Epileptic  convulsions  in  haemorrhage  do  not 
proceed  from  the  spinal  cord." 


5-  "Neither  do  they  proceed  from  the  cere- 
brum." 

7.  "Their  central  seat  is  to  be  sought  for  in  the 
excitable  districts  of  the  brain  lying  behind  the  thalami 
optici." 

8.  "Anaemia  of  those  parts  of  the  brain  situated 
in  front  of  the  crura  cerebri  produces  unconsciousness, 
insensibility,  and  paralysis  in  human  beings;  if  spasms 
occur  with  these  symptoms,  some  excitable  parts  be- 
hind the  thalami  optici  must  have  likewise  undergone 
some  change." 

9.  "  Anaemia  of  the  spinal  cord  produces  paraly- 
sis of  the  limbs,  of  the  muscles  of  the  trunk,  and  of 
respiration.  When  the  anaemia  suddenly  attains  its 
greatest  intensity,  then  only,  and  even  then  but  rarely, 
do  slight  trembling  of  the  limbs  precede  paralysis. 
The  sphincter  ani  acts  analogously  to  the  constrictor 
muscle  of  the  face  in  anaemia  of  the  brain^that  is,  it 
contracts  spasmodically  before  it  relaxes." 

A  more  explicit  account  of  the  experiments  from 
which  Kussmaul  and  Tenner  derived  these  conclusions 
has  already  been  given  in  the  paragraphs  on  "Experi- 
mental Researches."  These  experiments  constitute, 
without  doubt,  one  of  the  most  brilliant  chapters  in  the 
whole  range  of  experimental  pathology,  and  it  is  diffi- 
cult to  conceive  how  a  theory  of  epilepsy  possessing 
the  slightest  title  to  consistency  could  have  been  for- 
mulated had  they  never  been  undertaken. 

While  it  is  doubtful  whether  some  of  the  opinions 


—  149  — 

expressed  by  these  gifted  authors  can  at  present  re- 
ceive unqualified  indorsement,  there  is  no  denying 
the  great  perspicuity  displayed  throughout  the  entire 
argument.  When  interpreted,  moreover,  from  the 
broad  standpoint  of  more  recent  scientific  acquisitions, 
their  importance  to  scientific  medicine  can  hardly  be 
overestimated. 

Finally,  I  will  add  that  I  have  been  able  to  con- 
firm many  of  the  statements  and  conclusions  of  Kuss- 
maul  and  Tenner  by  researches  conducted  on  human 
beings.  As  I  shall  have  occasion  to  refer  at  some 
length  to  these  researches  in  other  portions  of  this 
article,  I  will  content  myself  with  merely  indicating 
the  titles  of  the  more  important  papers  and  mono- 
graphs in  which  they  are  embodied.* 

*  Vide  "Medical  Record,  '  February  18,1882.  Article 
on  "Sleep,"  "Medical  Record  "  July,  1872.  Monograph  on 
"Carotid  Compression,"  Anson  D.  F.  Randolph  &  Co.,  New 
York.  1882.  Paper  read  before  the  New  York  Neurological 
Society,  June  6,  1882,  and  subsequently  published  in  the  "  Phil- 
adelphia News"  of  June  17,  1S82,  and  also  in  the  "Ameri- 
can Journal  of  Neurology  and  Psychiatry,"  1882.  A  paper  on 
"  Electrization  of  the  Sympathetic  and  Pneumogastric  Nerves, 
with  Simultaneous  Bilateral  Compression  of  the  Carotids," 
"  New  York  Medical  Journal,"  February  23,  1884.  Monograph 
on  "Brain  Rest,"  G.  P.  Putnam's  Sons,  New  York,  1883.  A 
treatise  on  "  Brain  Exhaustion,"  with  some  preliminary  con- 
siderations on  cerebral  dynamics,  by  J.  Leonard  Corning, 
M.  D.,  D.  Appleton  &  Co.,  1884.  "The  Electro-mechanical 
Tonus  of  the  Cortical  Blood-vessels,"  a  paper  read  before  the 
New  York  Neurological  Society,  and  subsequently  published 
in  the  "  Medical  Record,"  February,  1885. 


—  15°  — 

Nothnagel,*  as  we  have  already  seen,  has  formu- 
lated a  theory  of  the  paroxysm,  which  is  the  outgrowth 
of  a  series  of  experiments  performed  with  the  object  of 
determining  the  role  played  by  the  medulla  oblongata 
and  pons  varolii  in  the  evolution  of  general  convulsive 
phenomena.  In  the  course  of  these  investigations 
this  observer  ascertained  that  there  is  a  limited  spot 
in  the  floor  of  the  fourth  ventricle,  the  irritation  of 
which  (with  a  needle,  etc.,)  causes  tonic  and  clonic 
spasms  of  the  entire  system  of  voluntary  muscles. 
This  spot  has  been  appropriately  designated  by  him 
as  the  "  convulsion  center." 

According  to  Nothnagel's  theory,  the  convulsions 
of  the  epileptic  paroxysms  are  due  to  irritation  of  this 
circumscribed  locality. 

But,  while  such  irritation  is  sufficient  to  evoke  the 
spasms,  it  is  not  adequate  to  account  for  the  uncon- 
sciousness. Accordingly,  to  overcome  this  difficulty, 
Nothnagel  assumes  a  concomitant  irritation  of  the 
neighboring  vaso-motor  center.  As  a  result  of  this 
irritation  the  arteries  of  the  brain,  as  well  as  those  of 
the  rest  of  the  body,  are  contracted,  causing  anaemia; 
and  it  is  to  this  cerebral  anaemia  that  the  unconscious- 
ness is  due.  The  co-ordinate  excitation  of  the  vaso- 
motor and  "  convulsion  centre  "  constitutes,  then,  ac- 
cording to  this  theory,  the  essential  pathological  fea- 
ture of  the  typical  paroxysm. 


*  "Uber   den  epileptischen  Anfall,"  von  H,  Nothnagel. 
Volkmann's  "  Sammlung  klinischer  Vortrage,"  Leipzig,  1872. 


—   151   — 

But,  while  this  is  assumed  to  be  the  course  of 
events  in  typical  cases,  it  does  not  serve  to  explain 
the  occurrence  of  variations  in  the  character  of  the 
seizure. 

Accordingly,  with  a  view  to  rendering  the  theory 
as  broad  as  possible,  Nothnagel  furthermore  assumes 
that  the  centres  above  referred  to  are  in  a  certain 
sense  independent  of  each  other,  so  that  one  may  be 
irritated  without  the  other.  Thus,  when  the  "con- 
vulsion center"  is  irritated  alone,  the  paroxysm  is 
characterized  by  convulsions  without  unconsciousness; 
whereas,  when  the  "  vaso-motor  center  "  is  excited 
mental  disturbances  and  loss  of  consciousness  are  the 
prominent  features. 

This  is  certainly  an  ingenious  method  of  avoid- 
ing a  logical  dilemma;  but,  unfortunately,  the  extreme 
contiguity  of  the  two  centres  renders  their  indepen- 
dent irritation  exteremely  improbable,  since  any  mor- 
bid changes  affecting  the  one  would  be  practically  cer- 
tain to  involve  the  other. 


CHAPTER  XI. 

CONCERNING  THE   NATURE  OF  THE  IRRITATION 

—THEORIES  OF  NOTHNAGEL.  TODD 

AND  HUGHLINGS  JACKSON. 

With  regard  to  the  nature  of  the  irritation  which 
calls  forth  the  activity  of  the  above-named  centers, 
Nothnagel  confesses  that  little  can  be  said  with  cer- 
tainty.* He  believes,  however,  that  in  epilepsy  "  the 
convulsions  do  not  depend  upon  an  anaemia  of  the 
pons,  acting  as  an  excitant  upon  the  convulsion 
centre;"f  though  admitting  that  anaemia  of  the  pons 
can  occasion  convulsions,  as  shown  by  certain  of  Kuss- 
maul's  experiments. 

As  to  the  second  stage  of  the  attack,  Nothnagel 
believes  that  the  intense  venous  hyperaemia  is  attribut- 
able to  the  violent  contractions  of  the  muscles  of  the 
neck,  which,  pressing  upon  the  large  veins,  impede 
the  return  of  the  venous  blood  to  the  heart.  The 
continuance  of  unconsciousness,  as  well  as  the  con- 
vulsions, are  to  be  ascribed  to  this  venous  hyperaemia, 
one  of  the  effects  of  which  is  to  cause  irritation  of  the 
"convulsion  center." 

It  now  remains  to  consider  briefly  that  theory  of 


*Von  Ziemssen's  "Cyclopaedia,"  article  "  Epilepsy,"  by 
H.   Nothnagel,  vol.  xiv;  p.  269,  seventeenth  line  from  the  top. 
fOp.  cit.,  p.  268. 


—  '53  — 
epilepsy  which  ascribes  the  essential  feature  of  the  dis- 
ease to  a  discharge  or  explosion  of  nerve  force.  Dr. 
Robert  B.  Todd*  was  the  first  to  regard  the  disease 
from  this  point  of  view.  It  is  impossible  to  read  the 
paper  in  which  this  gifted  writer  formulates  his  views 
upon  this,  one  of  the  most  intricate  chapters  in  pathol- 
ogy, without  experiencing  a  sense  of  admiration  for 
the  perspicuity  and  logical  adroitness  displayed. 

Dr.  Todd  considers  that  the  abnormal  explosive- 
ness  of  nervous  tissue,  which  is  the  principal  factor  in 
his  theory  of  epilepsy,  is  due  to  the  gradual  accumula- 
tion of  a  morbid  material  in  the  blood.  This  foreign 
substance  finally  becomes  so  abundant  as  to  cause  the 
discharge  of  nerve  force  from  the  brain,  by  which  the 
phenomena  of  the  fit  are  produced. 

This  theory  of  epilepsy  was  suggested  to  the 
mind  of  Dr.  Todd  from  the  fact  that  the  disease  oc- 
casionally occurs  with  renal  affections.  "  Upon  this 
fact  of  the  dependence  of  attacks  of  epilepsy  upon 
renal  disease,"  he  says,  "  I  have  been  enabled  to  con- 
struct a  theory  of  the  cause  of  epileptic  fits  generally." 
Continuing  the  argument,  he  adds:  "  I  hold  that  the 
peculiar  features  of  an  epileptic  seizure  are  due  to  the 
gradual  accumulation  of  morbid  material  in  the  blood, 
until  it  reaches  such  an  amount  that  it  operates  upon 


*A  Clinical  Lecture  on  a  Case  of  Renal  Epilepsy,  and  on 
the  Treatment  of  Epilepsy  in  General,"  by  Robert  B.  Todd, 
M.  D.,  Medical  Times  and  Gazette,  Aug.  5,  1854. 


—  154  — 
the  brain  in,  as  it  were,  an  explosive  manner;  in  other 
words,  the  influence  of  this  morbid  matter,  when  in 
sufficient  quantity,  excites  a  highly  polarized  state  of 
the  brain,  or  of  certain  parts  of  it,  and  these  discharge 
their  nervous  power  upon  certain  other  parts  of  the 
cerebro-spinal  center  in  such  a  way  as  to  give  rise  to 
the  phenomena  of  the  fit.  A  very  analogous  effect  is 
that  which  results  from  the  administration  of  strych- 
nine, which  is  best  seen  in  a  cold-blooded  animal  like 
the  frog.  You  may  administer  this  drug  in  very 
minute  quantities  for  some  time  without  producing 
any  sensible  effect;  but,  when  the  quantity  has  ac- 
cumulated in  the  system  up  to  a  certain  point, 
then  the  smallest  increase  of  dust  will  immediately 
give  rise  to  the  peculiar  convulsion  phenomena.  The 
animal  is  thrown  into  a  series  of  paroxysms  of  opistho- 
tonos, which  exactly  imitate  the  phenomena  which  we 
often  witness  in  tetanus,  as  it  affects  man  and  some  of 
the  higher  animals."* 

This,  then,  is  Dr.  Todd's  conception  of  the  causa- 
tion of  the  paroxysm — the  so-called  humoral  theory  of 
epilepsy. 

The  theory  enunciated  by  Dr.  Todd  has  been 
modified  and  developed  by  Hughlings  Jackson. f  Ac- 
cording to  Dr.  Jackson,  epilepsy,  "  defined  from  the 
paroxysm,  is  a  sudden,  excessive,  and  rapid  discharge 
of  gray  matter  of  some  part  of  the  brain;  it  is  a  local 


*0p.  et  loc.  cit. 

f  "West  Riding  Lunatic  Asylum  Medical  Reports,"  1873. 


—  155  — 
discharge.  To  define  it  from  the  functional  altera- 
tion, we  say  there  is  in  a  case  of  epilepsy  gray  matter 
which  is  so  abnormally  nourished  that  it  occasionally 
reaches  very  high  tension,  and  therefore  occasionally 
explodes.  The  two  definitions  are  different  faces  of 
the  same  thing." 

The  discharge,  beginning  at  the  cortex,  is  propa- 
gated along  the  course  of  the  centrifugal  nerve  chan- 
nels. As  to  the  loss  of  consciousness,  Dr.  Jackson 
feels  justified  in  ascribing  it  to  the  transitory  exhaus- 
tion of  nervous  energy,  consequent  upon  the  previous 
inordinate  discharge. 

The  fact  that  in  a  considerable  number  of  epilep- 
tics the  paroxysm  is  ushered  in  by  a  psychical  warning, 
or  an  aura  of  special  senses,  has  been  urged  as  strong 
evidence  in  favor  of  the  proposition  that  the  discharge 
begins  in  the  convolutions.  And,  in  truth,  it  must  be 
acknowledged  that  it  is  difficult  to  conceive  how  a 
primary  functional  implication  of  the  medulla  or  pons 
Varolii  could  evoke  phenomena  which,  by  common 
consent,  are  conceded  to  be  the  expression  of  the  ac- 
tivity of  the  highest  centres. 

According  to  this  theory,  then,  the  protoplasm  of 
the  ganglion  cells  is  in  an  unstable,  super-explosive 
condition,  attributable,  perhaps,  to  excessive  nutrition 
(as  the  result  of  expanded  blood-vessels,  etc.).  Jack- 
son has  not,  however,  remained  content  with  explain- 
ing the  modus  operandi  of  the  ordinary  epileptic  par- 
oxysm, but  has  also  sought  to  render  his  theory  sufifi- 


-  X56  - 

ciently  comprehensive  to  account  for  the  evolution  of 
irregular  forms  of  the  attack.  Accordingly,  it  is 
assumed  that  in  one  class  of  cases  certain  portions  of 
the  gray  matter  may  be  affected,  while  in  a  second 
class  of  cases  other  portions  may  be  involved.  The 
various  modifications  of  the  seizure  are,  therefore,  ex- 
plained by  a  consideration  of  the  physiological  pro- 
perties of  the  group  of  nerve-cells  involved  in  each 
case. 

While  heartily  indorsing  the  main  features  of  this 
theory,  I  cannot  accept  it  in  all  its  details,  for  the 
very  excellent  reason  that  cerebral  physiology  is 
not  as  yet  sufficiently  developed  to  admit  of  such 
pathological  refinements. 


CHAPTER  XII. 

PROGNOSIS— TREATMENT. 

From  the  very  earliest  periods  of  recorded  history- 
epilepsy  has  been  regarded  as  a  grave  disease. 
Doubts  of  its  curability  have  been  expressed,  even  at 
the  present  day;  this,  however,  according  to  such  ex- 
cellent authorities  as  Herpin  and  Nothnagel,  is  the 
extreme  of  pessimism  and  is  not  sustained  by  clinical 
experience. 

When  the  disease  begins  early  in  life,  say  before 
the  eighteenth  year,  the  prognosis,  all  things  being 
equal,  is  more  favorable  than  when  the  disease  comes 
on  late  in  life. 

In  those  cases  where  the  first  attack  is  traceable 
to  a  peripheral  cause,  the  prospects  of  recovery,  pro- 
vided we  succeed  in  removing  such  cause,  is  greater 
than  when  we  have  to  do  with  a  gross  central   lesion. 

Long  intervals  between  the  attacks  are  considered 
of  favorable  import  by  some,  but  by  others  they  are 
believed  to  presage  a  doubtful  recovery. 

The  character  of  the  seizure  has  no  great  influ- 
ence on  the  prospects  of  recovery;  and  in  forming  an 
opinion  on  that  question  we  may  apply  about  the 
same  course  of  reasoning  to  a  case  of  grand  mal  as  to 
one  of  minor  epilepsy. 

The  principal  methods  of  treating  the  disease  in 


-  158  - 

vogue  at  the  present  day  resolve  themselves  into 
surgical  procedures  (medicinal)  measures  and  dietetic 
expedients. 

By  resort  to  surgery  we  remove  an  offending 
cicatrix,  the  irritation  emanating  from  which  may 
cause  the  explosive  condition  resulting  in  the  seizures. 
The  same  means  also  enable  us  to  elevate  a  depression 
in  the  skull,  and  to  remove  by  the  aid  of  the  trephine 
irritating  substances  from  the  surface  of  the  meninges, 
Happy  results  soon  followed  such  applications  of 
surgery;  but  unfortunately  the  number  of  cases  sus- 
ceptible of  such  treatment  is  relatively  small,  so  that 
in  the  majority  of  cases  we  have  to  rely  upon  the  in- 
troduction of  chemicals  into  the  system,  and  upon 
careful  regulation  of  the  diet  to  prevent  or  diminish 
the  frequency  of  the  seizures. 

The  chemicals  which  have  been  employed  as 
medicines  in  the  treatment  of  epilepsy  aie  legion. 
Among  those  which,  at  one  time  or  another,  have  en- 
joyed a  wide  celebrity  I  would  mention  the  following: 
Valerian,  wormwood,  hyoscyamus,  belladonna,  oxide 
of  zinc,  nitrate  of  silver,  and  in  the  form  of  inhalations, 
chloroform,  ether,  and  the  nitrite  of  amyl.  During  the 
last  ten  years  the  bromides  have  become  the  fashion- 
able remedies  in  epilepsy.  At  one  time  great  things 
were  expected  from  electricity,  and  while  these  expec- 
tations have  not  been  entirely  realized,  it  must  be  con- 
ceded that  great  benefits  are  occasionally  witnessed 
from  the  application  of  the  constant  galvanic  current 


—  159  — 
about  the  head.  I,  myself,  have  frequently  witnessed 
diminution  of  the  number  of  seizures  subsequent  to 
prolonged  applications  of  weak  galvanic  currents  to  the 
head.  The  faradic  current,  on  the  contrary,  is  of  no 
particular  use  even  in  the  treatment  of  epilepsy. 

The  first  question  which  naturally  suggests  itself 
to  the  physician  in  connection  with  the  treatment  of 
epilepsy  is:  "What  shall  we  do  when  the  attack  has 
already  begun  ?"  We  answer,  if  the  attack  be  of  brief 
duration,  a  masterly  inactivity  is  the  prime  desider- 
atum. But  if,  on  the  contrary,  we  have  to  do  with  the 
status  epilepticus,  with  one  seizure  following  the  other 
in  rapid  succession,  we  should  by  all  means  abate  the 
attack.  This  may  be  attained  in  almost  all  cases  by 
applying  firm  pressure  to  the  stems  of  both  com- 
mon carotid  arteries  with  the  fingers,  or,  better  still, 
with  one  of  the  instruments  which  I  had  constructed 
several  years  since  for  the  purpose.*  The  implement 
in  question  consists,  in  the  first  place,  of  two  curved 
metallic  branches,  resembling  in  shape  an  inverted 
horseshoe.  At  each  of  the  extremities  of  the  horn  is 
a  small  padded  piece  of  metal,  which  may  be  set  at  an 
angle  by  means  of  a  key.     The  object  of  this  arrange- 


*"  Prolonged  Instrumental  Compression  of  the  Primi- 
tive Carotid  Artery  as  a  Therapeutic  Agent,"  by  J.  Leonard 
Corning,  M.  D.  The  Medical  Record,  Feb.  i8th,  1882.  Also 
"Carotid  Compression."  Ibid.  Anson  D.  F.  Randolph  & 
Co.,  New  York,  1882. 


—   i6o  — 

ment  is  to  permit  of  so  arranging  the  pads  that  the 
artery  is  pressed  away  from  the  jugular  vein,  in  the 
direction  of  the  spinal  column.  The  toe  of  the  horse- 
shoe is,  furthermore,  so  secured  to  a  handle  by  pivots 
that  by  rotating  a  screw  the  arms  of  the  horseshoe 
may  be  opened  or  approximated  at  will. 

When  employing  the  instrument,  the  patient,  if  in 
bed,  or  on  the  floor,  is  placed  in  a  horizontal  or  semi- 
dorsal  position,  with  the  head  supported  by  a  cushion 
beneath  the  neck,  in  such  a  manner  as  to  allow  the 
the  cranium  to  fall  slightly  backward,  thus  causing  a 
protrusion  of  the  cervical  vertebrae,  in  an  anterior 
direction.  The  operator  then  takes  his  place  at  the 
side  of  the  patient,  and  proceeds  to  ascertain  by  care- 
ful exploration  the  exact  location  of  the  carotids. 
Having  accompli.shed  this,  he  next  applies  the  instru- 
ment in  such  wise  that  the  pads  will  press  the  arteries 
away  from  the  pneumogastric  nerves  and  jugular  veins 
in  the  direction  of  the  spinal  column.  By  pressing 
one  hand  against  the  posterior  portion  of  the  neck,  it 
is  possible  to  execute  any  amount  of  counter-pressure. 
Compression  should,  however,  never  be  carried  to 
such  a  degree  as  to  cause  entire  closure  of  the  lumina 
of  both  arteries. 

Besides  the  device  just  described,  I  have  also  had 
made  for  me  appliances,  by  the  use  of  which  it  is  pos- 
sible to  employ  compression  of  the  carotids  for  pro- 
longed periods  of  time,  with  or  without  simultaneous 


—   i6i   — 

galvanization  of  the  sympathetic  and  pneumogastric 
nerves."^ 

Not  only  is  it  possible  to  arrest  the  succession  of 
paroxyms  peculiar  to  the  status  epilepticus  in  the  man- 
ner above  described,  but  it  is  also  sometimes  possible 
to  prevent  the  occurrence  of  seizures  for  weeks  to- 
gether, by  maintaining  continuous  compression  of  the 
carotids,  f 

As  an  adjunct  to  the  treatment,  then,  carotid- 
compression,  by  the  aid  of  appropriate  appliances  is  a 
most  valuable  expedient,  especially  when  combined 
with  the  administration  of  the  bromides. 

'  Of  these  last  mentioned  remedies  it  is  now  neces- 
sary to  speak.  During  the  last  ten  or  fifteen  years 
the  bromides,  and  especially  the  bromide  of  potassium, 
have  been  more  employed  in  epilepsy  than  any  other 
remedies  heretofore  recommended.  In  order  to  pro- 
duce the  best  results,  it  should  be  given  in  doses  vary- 
ing from  fifteen  to  forty-five  or  even  fifty  grains.  Very 
young  children  are,  however,  sometimes  benefited  by 
small  doses  of  from  six  to  ten  grains.  While  the 
potassium  salt  is  preferred  by  some  neurologists,  the 
sodium  salt  has  been  praised  by  others.     For  my  own 


*  For  a  further  description,  as  well  as  for  illustrations 
showing  these  appliances,  see  the  New  York  Medical  Journal 
for  February  23,1884.  Also  "Brain  Rest,"  by  J.  Leonard 
Corning,  M.  D.  Second  edition.  G.  P.  Putnam's  Sons,  New 
York,  1885. 

f  The  "  Medical  Record,"  February  18,  1882. 


l62     

part,  I  must  confess  that  I  prefer  a  mixture  of  these 
two  salts,  or  still  better  a  solution  containing  the 
amonium,  the  potassium,  the  sodium  and  the  lithium 
salts.     The  following  is  a  simple  formula  : 

IJ      Bromide  potassii. 

Bromide  amonii. 

Bromide  lithii, 

Bromide  sodii,  aa  Z  ij- 

Aquae,   3  vj. 
M. 
Dose,  from  one  to  four  teaspoonsful  three  times  a  day. 

By  the  concurrent  administration  of  arsenic  the 
troublesome  eruption  of  acne,  which  frequently  follows 
the  exhibition  of  the  bromides,  may  sometimes  be  pre- 
vented. The  rash  having,  however,  made  its  appear- 
ance, it  is  well  to  cut  down  the  dose  of  the  bromides 
at  once,  or  even  to  discontinue  their  administration 
for  a  time  altogether.  During  the  interim  the  oxide 
of  zinc  may  be  given  in  doses  of  from  one  to  five 
grains.  In  this  way  it  is  often  possible  to  prevent  the 
recurrence  of  the  attacks,  which  may  easily  happen,  if 
the  patient  is  deprived  of  all  medicine  for  some  days. 

Where  there  is  a  suspicion  of  syphilis  the  iodide 
of  potassium  should  be,  of  course,  at  once  resorted  to. 
To  obtain  the  best  results  it  should  be  given  in  large 
doses. 


CHAPTER  XIII. 

TREATMENT   CONTINUED— EPILEPTIC 
INSOMNIA. 

As  disorders  of  sleep  constitute  an  important 
feature  of  almost  all  forms  of  functional  nervous  de- 
rangement, it  is  important  to  possess  some  knowledge 
of  this  complication,  inasmuch  as  without  such  knowl- 
edge the  physician  speedily  finds  that  his  efforts  at 
amelioration  are  at  once  annoying  to  the  patient  and 
barren  of  results.  Before  taking  up  the  treatment  of 
that  distressing  and  destructive  form  of  sleeplessness 
which  is  such  a  frequent  accompaniment  of  epilepsy, 
I  desire  to  say  a  word  or  two  regarding  sleeplessness 
in  general:  To  begin,  then,  insomnia  may  be  classi- 
fied into  two  principal  divisions,  primary  or  idiopathic 
insomnia  and  secondary  or  symptomatic  insomnia. 
By  primary  insomnia  we  understand  that  form  of 
sleeplessness  which  is  directly  traceable  to  some  dis- 
turbances of  the  brain  itself.  This  is  the  variety  of 
insomnia  with  which  we  are  most  frequently  con- 
cerned in  the  treatment  of  epilepsy. 

When  we  speak  of  secondary  insomnia  we  mean 
that  form  of  sleeplessness  which  may  be  traced  to 
some  corporeal  disturbance  external  to  the  brain  itself, 
but  which,  acting  on  the  cerebral  mechanism  through 
the  agency   of  the  centripetal    nerves  gives  rise  to  a 


—  164  — 

degree  of  irritation  sufficient  to  prevent  the  superven- 
tion of  unconsciousness.  The  symptoms  of  both  the 
idiopathic  and  symptomatic  varieties  of  the  affection 
resemble  each  other  closely,  so  that  a  general  de- 
scription is  all  that  is  needed. 

A  person  afflicted  with  insomnia,  but  otherwise 
exempt  from  serious  nervous  difficulty,  complains 
either  that  he  cannot  fall  asleep,  or  that,  although  he 
may  succeed  in  maintaining  unconsciousness  through- 
out the  night  his  sleep  "  does  him  no  good,"  as  he  is 
in  the  habit  of  expressing  it.  The  first  phase  of  the 
affection,  characterized  by  difficulty  in  falling  asleep, 
is  familiar  to  persons  who  are  laboring  under  great 
emotional  or  mental  strain,  and  who  carry  their  busi- 
ness or  worry  to  bed  with  them.  Difficulty  of  main 
taining  the  condition  of  unconsciousness,  that  state  in 
which  the  patient  awakes  soon  after  falling  asleep  or 
during  the  early  morning  hours, — is  frequently  en- 
countered among  those  who  are  addicted  to  abuses  of 
the  table;  while  the  ability  to  sleep  through  the  night, 
and  yet  to  experience  scant  refreshment  from  such 
protracted  slumber,  represents  a  pathological  condi- 
tion peculiar  to  those  who  are  the  victims  of  uncon- 
scious cerebration  or  dreaming  or  both.  Those  who 
are  victims  of  this  morbid  cerebral  condition  simply 
carry  on  their  mental  efforts  unconsciously,  but 
though  laboring  thus,  all  unbeknown  to  themselves, 
the  consumption  of  cerebral  energy  goes  on  apace,  so 
that  there  is  little  or  no  repose  whatever. 


-  i65  - 

Persons  who  are  the  victims  of  this  derangement 
suffer  immensely,  not  the  least  of  their  troubles  con- 
sisting in  their  total  inability  to  account  for  the  feel- 
ings of  lassitude  which  assail  them  immediately  on 
rising  from  what  they  imagine  to  be  a  perfect  type  of 
sleep. 

Besides  dreaming  and  unconscious  cerebration, 
derangements  of  the  liver  and  kidneys  sometimes  pro- 
duce this  morning  lassitude,  and  the  same  may  be 
said  of  that  exhaustion  which  supervenes  npon  pro- 
tracted mental  labor,  worry,  or  both  combined. 

In  epileptics,  and  more  especially  in  those  who 
have  become  inmates  of  asylumns  in  consequence  of 
mental  trouble,  we  encounter  an  interesting  phase  of 
insomnia,  which,  for  most  practical  reasons  is  worthy 
of  study. 

This  variety  of  insomnia  comes  on  in  the  first 
place  as  the  sequence  of  an  attack:  the  patient  awakes 
from  the  comatose  condition  incident  to  the  attack; 
he  is  drowsy  and  may  sleep  for  a  considerable  length 
of  time,  but  the  same  night  he  is  restless  and  may  fail 
to  procure  even  an  hour  of  sleep,  and  on  the  follow- 
ing morning  gives  unmistakable  evidence  of  having 
suffered  severely  from  the  involuntary  vigil. 

Sometimes,  again,  the  attack  of  insomnia  comes 
on  with  no  other  warning  than  an  unusual  degree  of 
restlessness  or  irritability.  The  effects  of  these  en- 
forced vigils  in  persons  afflicted  by  such  a  grave  dis- 
ease as  epilepsy  are  often  of  a  most  disastrous  char- 
acter. 


—   i66  — 

Sometimes  the  attack  of  insomnia  is  followed  by 
a  terrible  outburst  of  maniacal  furor,  while  in  a  cer- 
tain number  of  cases  there  is  a  well-marked  increase 
in  the  number  of  convulsive  seizures.  Again,  in  a 
milder  class  of  cases,  the  general  health  of  the  patient 
undergoes  rapid  deterioration;  he  becomes  irritable 
and  subject  to  attacks  of  depression;  his  complexion 
becomes  sallow;  his  face  assumes  a  stupid,  emotion- 
less expression;  he  loses  flesh,  and,  in  short,  falls  into 
a  rapid  decline,  with  but  one  prospect,  that  of  speedy 
dissolution. 

The  more  I  have  seen  of  epilepsy  the  more  have 
I  become  convinced  of  the  necessity  of  treating  sys- 
tematically and  promptly  this  epileptic  variety  of  in- 
somnia. Fortunately,  the  problem  involved  is  not  so 
difficult  as  it  might  appear  at  first  sight.  In  the  first 
place  the  patient  should  be  continuously  saturated 
with  the  bromides,  but  not  bromized.  He  should  be 
given  from  thirty  to  seventy-five  grains  a  day,  each 
dose  to  be  combined  with  one  or  two  minims  of  the 
liquor  arsenicalis.  Given  in  this  way  the  bromides 
many  be  continued  for  many  years,  if  need  be.  In 
severe  cases  it  may  be  necessary  to  increase  the  dose 
still  further,  as  we  have  already  seen;  but,  in  a  con- 
siderable percentage  of  cases,  this  dosage  will  be  found 
sufficient  to  prevent  the  attacks,  and  at  the  same  time 
to  exert  a  progressively  tranquilizing  influence  upon 
the  cerebrum  as  night  approaches.  At  bed-time,  or 
shortly  before  it,   twenty  or  thirty  grains  of  chloral 


—   167  — 

may  be  given,  combined  either  with  two  or  three 
drachms  of  the  tincture  of  hyoscyamus,  or  with  a 
drachm  of  the  bromide  of  potassium. 

Several  years  ago,  when  I  published  the  first 
edition  of  my  little  book  on  "  Brain  Rest,"  I  advocated 
the  seclusion  of  patients  afflicted  with  insomnia,  or  for 
whom  prolonged  sleep  had  been  prescribed  as  a  fea- 
ture of  treatment,  in  a  darkened  room.  I  can  only 
repeat  on  this  occasion  what  I  then  said  : 

The  subject  is  secluded  in  a  darkened  room  from 
ten  to  fifteen  hours  at  a  time,  according  to  the  amount 
of  sleep  which  it  is  desired  shall  be  had  during  the 
twenty-four  hours.  The  amount  of  sleep  is  progres- 
sively increased  by  habit,  moderate  medication,  and 
hydrotherapy,  and  no  attempt  is  made  to  produce  a 
sudden  state  of  stupor  by  the  reckless  use  of  sedatives. 
When  the  patient  awakes,  as  is  usually  the  case,  two 
or  even  three  times  during  the  hours  set  apart  for  rest, 
nourishment  is  administered,  but  always  in  a  fluid  and 
easily  digested  form.  Where  difficulty  is  experienced 
in  again  falling  asleep,  resort  is  had  in  the  beginning 
to  limited  medication.  The  few  hours  of  wakefulness 
are  devoted  exclusively  to  some  form  of  amusement 
— reading,  writing,  and  even  the  mildest  forms  of 
mental  concentration  being  absolutely  prohibited. 
This,  in  brief,  is  the  method  from  which  I  have  already 
seen  most  happy  results,  and  from  the  employment  of 
which  I  hope  and  believe  much  good  will  in  future  be 
derived.     It  is  hardly  necessary  to  say  that  the  prob- 


—  i68  — 

lem  of  cerebral  rest  is  essentially  different  and  pre- 
sents many  more  difficulties  than  spinal  rest.  To 
give  repose  to  the  motor  cells  of  the  cord  is  compara- 
tively an  easy  problem,  and  one  which  only  exacts  a 
permanent  fixation  of  the  motor  apparatus  for  its  solu- 
tion, the  consciousness  or  unconsciousness  of  the  in- 
dividual being  only  a  matter  of  secondary  importance. 
Rest,  however,  for  those  cells,  the  function  of  which 
is  the  evolution  of  mind,  can  only  be  obtained  by  a 
prolonged  period  of  absolute  unconsciousness;  and 
this,  as  a  matter  of  course,  will  often  tax  the  patience 
and  resources  of  the  physician  to  the  utmost.  Perse- 
verence  and  the  utilization  of  the  principle  of  habit 
will  usually,  however,  render  essential  assistance. 

These  are  the  views  which  I  expressed  in  1883,* 
when  discussing  the  most  rational  method  of  treating 
cerebral  exhaustion.  All  that  I  then  said  may  be 
properly  applied  to  the  treatment  of  a  large  number 
of  functional  nervous  affections,  and  particularly  in 
the  treatment  of  chorea  and  epilepsy.  So  manifestly 
important  is  the  question  of  sleep  in  the  treatment  of 
the  latter  aft'ections,  that  I  trust  I  have  not  trespassed 
too  much  upon  the  patience  of  the  reader,  by  discuss- 
ing the  matter  somewhat  at  length.  It  has  been  a 
matter  of  great  surprise  to  me  that  so  little  attention 
should  heretofore  have  been  bestowed  upon  this  im- 
portant matter  of  prolonged  sleep  in  the  treatment  of 

*  The  New  York  Medical  Journal  for  December  29,  1883. 


—  169  — 

convulsive  nervous  affections.  From  quite  an  exten- 
sive personal  experience  both  in  insane  asylum  and 
private  practice,  I  am  convinced  that  the  subject  is 
one  of  superlative  importance,  when  it  is  a  question  of 
restoring  derangements  of  cerebral  nutrition,  whether 
such  be  the  concomitants  of  exhaustive  or  convulsive 
conditions. 


INDEX- 


A.  Page.  , 

Amaurosis  in  Hysteria 39 

Amblyopia  in  Hysteria 39 

Anaesthesia  in  Hysteria 37 

Ansethetics 12 

Hysterical  Manifestation  Following  the  Admin- 
istration of  Anaesthetics  Generally  Occur 
in  Neurotic,  Hysterically  Inclined  Individ- 
uals    16 

Hysterical    Phenomena   Consequent  Upon  the 

Administration  of 12 

Lyman's  Cases  Illustrating  False  Beliefs  of 
Women  Engendered  by  the  Administration 

of 13 

Aurae  Epileptical 85 

Auditory 87 

Motor 88 

Olfactory 88 

Psychical 89 

Secretory 87 

Sensory 85 

Taste 88 

Vaso-motor 86 

Visceral 88 

Visual 87 

c. 

Carotids,  Compression  of  in  Epilepsy,  Coming's  Method 

of  Executing 159  ^^  J^/- 

Cerebral  Rest,  Coming's  System  of  Affording 167 

Contractures  in  Hysteria 45 


—  172  — 

Page. 

"  Convulsion  Center  " 131 

Convulsions 118 

Blood-letting  as  a  Cause  of;  Pioray  on,  Kellie 
on,  Marshall  Hall  on,   Sir  Astley  Cooper 

on iij  et  seq. 

Brown-Sequard  on 133 

Challand  on 136 

Landois  on  the   Relation   of  Venous   Hyperae- 

mia  to 129 

Magnan  on 136 

Nothnagel's  Researches   on 131 

Kussmaul  and  Tenner  on  the   Physiology  of, 

120  et  seq. 
Westphal  on 135 

E. 

Epilepsy 83 

Age  in in 

Alcohol  in in 

Aathor's  Statistics  on  the  Relative  Frequency  of 

in  Men  and  Women in 

Bromides  in 161 

Brown-Sequard  on 133 

Carotid-Compression    in.     Coming's    Researches 

Regarding 159 

Causation  of IC9 

Classification  of 83 

Cooper,  Sir  Astley,   Researches  of,  on 118 

Cranial  Injury  in 114 

Excesses  in 112 

Experimental  Researches  on 117 

Fever  in 113 

Gower's  Statistics  in in 

Heredity  in no 


—  173  — 

Page. 

Epilepsy  Hippocrates'  Views  Regarding 117 

Insomnia  of 163 

Iodide  of  Potassium  in 162 

Irregular  forms  of  (Masked  Epilepsy) 99 

*' Jacksonian  " 104 

Kellie  on 117 

Kussmaul  and  Tenner  on 120  et  seq . 

Landois  on 129 

Major  Variety  of 90 

Marshall  Hall  on 118 

Minor  Variety  of 95 

Nothnagel  on 131 

Patho-anatomical  Findings  in 139  ^^  seq. 

Pioray  on 117 

Prognosis  of 157 

Prolonged  Sleep  in 167 

Sensory 107 

Sex  in tii 

Symptoms  of 84 

Thalamic 103 

Transition  forms  of 97 

Treatment  of 158  et  seq. 

Westphal  on 135 

Zinc  in 162 

Epileptic  Seizure,  Mechanism  of 142 

Hughlings  Jackson  on 154 

Kussmaul  and  Tenner  on 143 

Marshall  Hall  on 143 

Nothnagel  on 150 

Todd  on,  "  Humoral "  Theory  of 153 

"  Epileptogenous  Zone" 134 

G. 

Globus  Hystericus,  Galvanism  in 81 

Grand  Mai 90 


—  174  — 

H. 

Hyperaesthesia  in  Hysteria 25 

Hysteria 1 

Case  from  Author's  Experience  Illustrating  Mor- 
bid  Impulse  to  Commit  Violence 19 

Causation  of 68 

Clauston's  Observations  on  Hysterical  Insanity.  .  21 

Contractures  in 46 

Cough,  Peculiar  in 50 

Craving  for  Sympathy  in 6 

Crimes  in 7 

Deception  in 6 

Definition  of i 

Diagnosis  of 72 

Hearing,  Exaltation  of   in 28 

HyperEesthesia  in 25 

in  Children 62 

in  Men   67 

Insanity  as  a  Complication  of 21 

Insanity  in  Case  of  Clauston  Illustrating 23 

Medico-Legal  Relations  of,  Importance  of 20 

Morbid  Impulses  to  Commit  Acts  of  Violence  in,  18 
Motive  for  Violent  Acts  in  not  Always  Ascertain- 
able    20 

Motor  Disorders  in 41 

Mutilation    in 8 

Notoriety  or  Desire  for  Sympathy  as  a  Cause  of 

Violent  Acts  in ig 

Ovarian  Troubles  as  a  Cause  of 3 

Ovaries,  Hyperaesthesia  of  in 30 

Pain,  Morbid  Sensibility  to  in 29 

Paralysis  in 44 

Paroxysmal   Attacks  in 57 

Pathology  of 70 


—   175   — 

Page. 

Hysteria,  Prognosis  of 74 

Psychical  Manifestations  of .  .  .      5 

Retention  in 8i 

Sensory  Disorders  in 25 

Sight  Exaltation  of  in.  .  .* 27 

Smell,  Exaltation  of  Sense  of  in 26 

Spasms  in 41 

Taste,  Exaltation  of  in.  .  . .    27 

Treatment  of 75 

Tremor  in 47 

Vaginismus  in,  Scanzoni  on,  Thomas  on 43 

Vaso-motor  Disorders  in .  . 49 

Hysterical  Attack,  The 57 

Hysterical  Cough 50 

Author's  Cases  of 54 

Hartley's  Remarkable  Cases  of 51 

Synclair's  "  Acute  "  Case  of 56 

Hystero-epilepsy 58 

I. 

Insomnia  of  Epilepsy 163 

Disastrous  Effects  of 165 

J. 

"  Jacksonian  "  Epilepsy 104 

Joints,  Painful,  in  Hysteria 33 

Brodie,  Sir  Benjamin  on 32 

Skey  on  Pain  in  Joints  in  Hysteria 34 

L. 

Larvated  Epilepsy 99 

M. 

Medico-Legal  Relations  of  Hysteria 20 


—  176  — 

Page. 
O. 

Ophthalmoscopic  Appearances,  Absence  of  Characteristic 

in  Hysteria 39 

Ovaries,  Hyperaesthesia  of,  in  Hysteria 30 

P. 

Pain  in  Hysteria 29 

Dorsal,  in  Hysteria 31 

Morbid  Sensitiveness  to,  in  Hysteria 29 

Ovarian,  in   Hysteria 30 

Paralysis  in  Hysteria 44 

Petit  Mai 95 

S. 

Sensory  Disorders  of   Hysteria 25 

"  Sensory   Epilepsy  " 107 

Sir  Benjamin  Brodie  on  Painful  Joints  in  Hysteria 32 

Spasms  in  Hysteria 41 

Suicide,  Fictitious  Attempts  at  on   the  Part  of    Hysterical 

Persons 16 

Case    Illustrating    Fictitious   Attempt   at  Self-de- 
struction from  the  Author's  Experience 17 

T. 

' '  Thalamic  "  Epilepsy 103 

Tremor  in  Hysteria 47 

V. 

Vaginismus  in  Hysteria,  Thomas  and  Scanzoni  on 43 

Violence,  Morbid  Impulse  to  Commit  Acts  of  Among  the 

Hysterical 18 

Visual  Disturbances  in  Hysteria 39 


ANODYNES  AND    HYPNOTICS. 


Necessity  for  Absolutely  Uniform  Preparations. 


Pain  is  the  most  marked  indication  of  disease.  To  assuaging  it  the  physician's 
first  and  best  efforts  are  directed,  and  to  the  patient  its  relief  is  the  tangible  evi- 
dence of  the  Doctor's  skill.  It  is  not  strange,  therefore,  that  anodynes  and 
hypnotics  play  so  important  a  part  in  the  medicinal  resources  of  every  physician. 

The  ideal  anodyne  and  hypnotic  free  from  reaction  or  disagreeable  after- 
effects remains  to  be  discovered.  Those  most  frequently  resorted  to  are  the  prep- 
arations of  opium,  the  bromides  and  chloral .  When  the  toxic  properties  of  these 
remedies  and  their  vast  consumption  is  considered,  the  necessity  for  the  employ- 
ment of  absolutely  uniform  and  pure  preparations  of  them  is  evident. 

We  beUeve  in  standardizing  toxic  drugs,  and  supply  a  line  of  standardized  fluid 
extracts  of  such  drugs  as  ergot,  aconite,  belladonna,  cannabis  indica,  gelsemium, 
foxglove,  nux  vomica  and  others,  and  believe  they  will  commend  themselves  to  all 
scientific  physicians. 

In  cases  in  which  opium  is  contra-indicated  many  physicians  use  with  satisfac- 
tion fluid  extract  Jamaica  dogwood  (Piscidia  erythrina),  which  is  both  an  anodyne 
and  hypnotic,  relieving  pain  and  securing  quiet,  refreshing  sleep,  and  which  is  free 
from  the  distressing  after-effects  of  opium  preparations. 

There  are  certain  proprietary  preparations  of  anodynes  largely  prescribed  by 
physicians  for  which,  at  the  solicitation  of  many  members  of  the  profession,  we 
have  prepared  scientific  substitutes  which  are,  we  believe,  equally  efHcient  and 
may  be  ethically  prescribed.  Thus  we  have  prepared  chloranodyne  as  an  improve- 
ment upon  the  well-known  proprietary  preparation  chloranodyne.  It  is  a  happy 
combination  of  well  known  sedatives,  anodynes  and  anti-spasmodics,  and  is  deserv- 
edly popular.  It  is  especially  serviceable  in  acute  intestinal  inflammations,  as 
colic,  dysentery  and  in  dyspepsia,  neuralgia,  toothache,  etc. 

Cerebral  sedative  compound  is  a  valuable  hypnotic  which  we  offer  as  a  scienti- 
fic substitute  for  bromidia.  We  prepare  two  formulae  of  it:  one  contains  potassium 
bromide,  chloral  hydrate,  gelsemium  and  opium.  In  the  second,  henbane  is  sub- 
stituted for  the  opium. 

We  have  also  a  line  of  pills  and  hypodermic  tablets  of  anodynes,  sedatives  and 
hypnotics. 

Descriptive  circulars,  giving  formulae  and  all  desired  information  regarding  our 
standardized  products  and  improved  pharmaceutical  preparations  furnished  on 
request. 

'    PAEKE,  DAVIS  &  CO., 

Manufacturing  Chemists, 


NEW  YORK: 
Offices,  60 
Warehous 
Crude  Drug  Warehouse,  218  Pearl  St 


Offices,  60  Maiden  Lane.  DFTROTT     WXCmdAM 

Warehouse  and  Shipping  Depot,  21  Liberty  St    L»C.  I  KUl  1 ,   lYllCHH:rAW. 


%\-}c  l^liDsici^D-s'  |Ccisi|i'c  |^ibJ>i)l-i), 


PRICE :  PAPER,  25  CTS.  PER  COPY,  $2.50  PER  SET ;  CLOTH,  50  CTS,  PER  COPY, 
$5,00  PER  SET. 


SERIES  I. 


Inhalers,  Inhalations  and  Inhalants. 
By  Beverley  Robinson,  M.  D. 

The  Use  of  Electricity  in  the  Removal  of 
Superfluous  Hair  and  the  Treatment  of 
Various  Facial  Blemishes.    _ 
By  Geo.  Henry  Fox,  M.  D. 

New  Medications.  ,,    ,^ 

By  Dujardin-Beaumetz,  M.  D. 

The  Modern  Treatment  of  Ear  Diseases. 
By  Samuel  Sexion,  M.  D. 

Spinal  Irritation.      ^,  ,    .,    r^ 

By  William  A.  Hammond,  M.  D. 

The  Modern  Treatment  of  Eczema. 
By  Henry  G.  Piffard,  M.  D. 


Antiseptic  Midwifery. 

By  Henry  J.  Garrigues,  M.  D. 

On  the  Determination  of  the  Necessity  for 
Wearing  Glasses.  _ 

By  L).  B.  6t.  John  Roosa,  M.  D. 

The  Physiological, Pathological  and  Ther- 
apeutic Effects  of  Compressed  Air. 
By  Andrew  H  .  Smith,  M.  D. 

GranularLids  and  ContagiousOPhthalmiai 
By  W.  F.  Mittendorf,  M.  D. 

Practical  Bacteriology. 

By  Thomas  E.  Satterthwaile,  M.  D. 

Pregnancy,  Parturition  and  the  Puerperal 
State  and  their  Complications- 
By  Paul  F.  Mund^,  M.  D. 


SERIES  II. 


The  Diagnosisand  Treatment  of  Haemor- 
rhoids. ,,  ,  .,    ^ 
By  Chas.  B.  Kelsey,  M.  D. 

Diseasesof  the  Heart.    Vol.1. 

By  Dujardin-Beaumetz,  M.  D. 

Diseasesof  the  Heart.    Vol.  (I. 

By  Dujardin-Beaumetz,  M    D. 

The  Modern  Treatment  of  Diarrhoea  and 
Dysentery.  ,,     ^ 

By  A.  B     Palmer,  M.   D. 

Intestinal  Diseases  of  Children. 
By  A.  Jacobi,  M.  D. 


The  Modern  Treatment  of  Headaches.  ^ 
By  Allan  McLane  Hamilton,   M.  D. 
The  Modern  Tieatment  of  Pleurisy  and 
Pneumonia. 

By  G.  M.  Garland,  M.  D. 

How  to  Use  the  Laryngoscope. 

By  an  Eminent  Laryngologist. 

Diseases  of  the  Male  Urethra. 

By  Kessenden  N.  Otis,  M.  D. 
The  Disorders  of  Menstruation.  _ 

By   Edward  W.   Jenks,  M.  D. 
The  Infectious  Diseases.  In  2  vols. 

By  Karl    Liebermeister. 


SERIES  III. 


Abdominal   Surgery. 

By  Hal  C.  Wyman,  M.  D.     Ready. 

Diseasesof  the  Liver.  ,,  „    „      . 

By  Dujardin-Beaumetz,  M.D.  Ready. 

Hysteria  and  Epilepsy.    .        ,^   „      . 
By  J.  Leonard  Corningr,  M.  D.    Aug. 

Diseases  of  the  Kidney.         ,,   r.     c 
By  Dujardin-Beaumetz,  M.  D.    Sept. 

The  Theory  and  Practice  of  the  Ophthal- 
moscope. 

By  J.  Herbert  Claiborne,  Jr.,  M.  D. 
September. 
Modern  Treatment  of  Bright's  Disease. 
By  Alfred  L.    Loomis,   M.  D. 
October. 


j    Clinical  Lectures  on  Certain   Diseases  Of 
I       Nervous  System. 

By  Prof.  J.  M.  Charcot,  M.  D. 
October. 
The  Radical  Cure  of  Hernia. 

Bv  Henry  O.   Marcy,  A.  M.,  M.  D., 
I..  L    D      November. 

The  Treatment  of  Diseases  of  the  Blad- 
der, Prostate  and  Urethra. 

By  H.  O.  Walker,  M.  D.     Nov. 

Dvspepsia.  _    , 

Hy  Frank  Woodbury,  M.  D.  Jan.  '89. 

The  Treatment  of  the  Morphia  Habit. 
By  Erlenmeyer.    December. 
Transla-ed  by  J.  B.  Mattison,  M.D. 


GEORGE    S.    DAVIS, 
PUBLISHER, 

:E=>.  O.  Bo2C  ^TO-  ^Detroit,    Is^icls.. 


-•e/Dco 


Inc. 


38. 


S93 


^ATe 


oue 


